1. A client asks the nurse what a third degree laceration is.

She was informed that she had one. 9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3
The nurse explains that this is: pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician
A. that extended their anal sphincter determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely
B. through the skin and into the muscles uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to:
C. that involves anterior rectal wall A. lie face down
D. that extends through the perineal muscle. B. not drink fluids
2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that C. practice holding breaths between contractions
the client understands her care at home when she says: D. assume Sim’s position
A. I am happy to note that we can have sex occasionally when I have no bleeding. 10. Which is true regarding the fontanels of the newborn?
B. I am afraid I might have an operation when my due comes A. The anterior is large in shape when compared to the posterior fontanel.
C. I will have to remain in bed until my due date comes B. The anterior is triangular shaped; the posterior is diamond shaped.
D. I may go back to work since I stay only at the office. C. The anterior is bulging; the posterior appears sunken.
3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal D. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
area at about the: 11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after
A. 8th week of pregnancy birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby
B. 10th week of pregnancy Quijones to weigh at 6 months?
C. 12th week of pregnancy A. 13 -14 lbs
D. 18th week of pregnancy B. 16 -17 lbs
4. Which of the following urinary symptoms does the pregnant woman most frequently experience C. 22 -23 lbs
during the first trimester: D. 27 -28 lbs
A. frequency 12. During the first hours following delivery, the post partum client is given IVF with oxytocin
B. dysuria added to them. The nurse understands the primary reason for this is:
C. incontinence A. To facilitate elimination
D. burning B. To promote uterine contraction
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her C. To promote analgesia
weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in D. To prevent infection
her pregnancy. 13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered
A. 20-30 lbs normal if the newborn is sleeping?
B. 25-35 lbs A. 80 beats per minute
C. 30- 40 lbs B. 100 beats per minute
D. 10-15 lbs C. 120 beats per minute
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept D. 140 beats per minute
should the nurse consider when implementing nursing care? 14. The infant with Down Syndrome should go through which of the Erikson’s developmental
A. Explain the surgery, expected outcome and kind of anesthetics. stages first?
B. Modify preoperative teaching to meet the needs of either a planned or emergency A. Initiative vs. Self doubt
cesarean birth. B. Industry vs. Inferiority
C. Arrange for a staff member of the anesthesia department to explain what to C. Autonomy vs. Shame and doubt
expect post-operatively. D. Trust vs. Mistrust
D. Instruct the mother’s support person to remain in the family lounge until after the 15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which
delivery. of the following complications?
7. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the A. Irreversible brain damage
following represents an unusual finding for this condition? B. Kidney failure
A. generalized edema C. Blindness
B. proteinuria 4+ D. Neutropenia
C. blood pressure of 160/110 16. Which age group is with imaginative minds and creates imaginary friends?
D. convulsions A. Toddler
8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal B. Preschool
bleeding that coitus: C. School
A. Need to be modified in any way by either partner D. Adolescence
B. Is permitted if penile penetration is not deep. 17. Which of the following situations would alert you to a potentially developmental problem with
C. Should be restricted because it may stimulate uterine activity. a child?
D. Is safe as long as she is in side-lying position. A. Pointing to body parts at 15 months of age.
B. Using gesture to communicate at 18 months.
 C. Cooing at 3 months. Situation 1: Raphael, a 6 year’s old prep pupil is seen at the school clinic for growth and
D. Saying “mama” or “dada” for the first time at 18 months of age. development monitoring (Questions 1-5)
18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and 1. Which of the following is characterized the rate of growth during this period?
temper tantrums. What is the best way to deal with her behavior? A. most rapid period of growth
A. Tell her that she would not be loved by others is she behaves that way.. B. a decline in growth rate
B. Withholding giving her toys until she behaves properly. C. growth spurt
C. Ignore her behavior as long as she does not hurt herself and others. D. slow uniform growth rate
D. Ask her what she wants and give it to pacify her. 2. In assessing Raphael’s growth and development, the nurse is guided by principles of growth
19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check- and development. Which is not included?
up. By this period, baby Villanueva has already increased his height by how many inches? A. All individuals follow cephalo-caudal and proximo-distal
A. 3 inches B. Different parts of the body grows at different rate
B. 4 inches C. All individual follow standard growth rate
C. 5 inches D. Rate and pattern of growth can be modified
D. 6 inches 3. What type of play will be ideal for Raphael at this period?
20. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put A. Make believe
under aerosol administration of Terbutaline. After sometime, you observe that the child does not B. Hide and seek
show any relief from the treatment given. Upon assessment, you noticed that both the heart and C. Peek-a-boo
respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect: D. Building blocks
A. Bronchiectasis 4. Which of the following information indicate that Raphael is normal for his age?
B. Atelectasis A. Determine own sense self
C. Epiglotitis B. Develop sense of whether he can trust the world
D. Status Asthmaticus C. Has the ability to try new things
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. D. Learn basic skills within his culture
Symptoms the nurse observes that suggest this problem include: 5. Based on Kohlberg’s theory, what is the stage of moral development of Raphael?
A. Lymphedema and nerve palsy A. Punishment-obedience
B. Hearing loss and ataxia B. “good boy-Nice girl”
C. Headaches and vomiting C. naïve instrumental orientation
D. Abdominal mass and weakness D. social contact
22. Which of the following danger sings should be reported immediately during the antepartum Situation 2 Baby boy Lacson delivered at 36 weeks gestation weighs 3,400 gm and height of 59
period? cm (6-10)
A. blurred vision 6. Baby boy Lacson’s height is
B. nasal stuffiness A. Long
C. breast tenderness B. Short
D. constipation C. Average
23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following D. Too short
symptoms would the nurse anticipate finding? 7. Growth and development in a child progresses in the following ways EXCEPT
A. periorbital edema, absent light reflex and translucent tympanic membrane A. From cognitive to psychosexual
B. irritability, purulent drainage in middle ear, nasal congestion and cough B. From trunk to the tip of the extremities
C. diarrhea, retracted tympanic membrane and enlarged parotid gland C. From head to toe
D. Vomiting, pulling at ears and pearly white tympanic membrane D. From general to specific
24. Which of the following is the most appropriate intervention to reduce stress in a preterm infant 8. As described by Erikson, the major psychosexual conflict of the above situation is
at 33 weeks gestation? A. Autonomy vs. Shame and doubt
A. Sensory stimulation including several senses at a time B. Industry vs. Inferiority
B. tactile stimulation until signs of over stimulation develop C. Trust vs. mistrust
C. An attitude of extension when prone or side lying D. Initiation vs. guilt
D. Kangaroo care 9. Which of the following is true about Mongolian Spots?
25. The parent of a client with albinism would need to be taught which preventive healthcare A. Disappears in about a year
measure by the nurse: B. Are linked to pathologic conditions
A. Ulcerative colitis diet C. Are managed by tropical steroids
B. Use of a high-SPF sunblock D. Are indicative of parental abuse
C. Hair loss monitoring 10. Signs of cold stress that the nurse must be alert when caring for a Newborn is:
D. Monitor for growth retardation A. Hypothermia
B. Decreased activity level
 C. Shaking C. Adenoid
D. Increased RR D. Nasopharynx
Situation 3 Nursing care after delivery has an important aspect in every stages of delivery 20. For acute otitis media, the treatment is prompt antibiotic therapy. Delayed treatment may
11. After the baby is delivered, the cord was cut between two clamps using a sterile scissors and result in complications of:
blade, then the baby is placed at the: A. Tonsillitis
A. Mother’s breast B. Eardrum Problems
B. Mother’s side C. Brain damage
C. Give it to the grandmother D. Diabetes mellitus
D. Baby’s own mat or bed 21. When assessing gross motor development in a 3 year old, which of the following activities
12. The baby’s mother is RH(-). Which of the following laboratory tests will probably be ordered would the nurse expect to finds?
for the newborn? A. Riding a tricycle
A. Direct Coomb’s B. Hopping on one foot
B. Indirect Coomb’s C. Catching a ball
C. Blood culture D. Skipping on alternate foot.
D. Platelet count 22. When assessing the weight of a 5-month old, which of the following indicates healthy growth?
13. Hypothermia is common in newborn because of their inability to control heat. The following A. Doubling of birth weight
would be an appropriate nursing intervention to prevent heat loss except: B. Tripling of birth weight
A. Place the crib beside the wall C. Quadrupling of birth weight
B. Doing Kangaroo care D. Stabilizing of birth weight
C. By using mechanical pressure 23. An appropriate toy for a 4 year old child is:
D. Drying and wrapping the baby A. Push-pull toys
14. The following conditions are caused by cold stress except B. Card games
A. Hypoglycemia C. Doctor and nurse kits
B. Increase ICP D. Books and Crafts
C. Metabolic acidosis 24. Which of the following statements would the nurse expects a 5-year old boy to say whose pet
D. Cerebral palsy gerbil just died
15. During the feto-placental circulation, the shunt between two atria is called A. “The boogieman got him”
A. Ductus venosous B. “He’s just a bit dead”
B. Foramen Magnum C. “Ill be good from now own so I wont die like my gerbil”
C. Ductus arteriosus D. “Did you hear the joke about…”
D. Foramen Ovale 25. When assessing the fluid and electrolyte balance in an infant, which of the following would be
16. What would cause the closure of the Foramen ovale after the baby had been delivered? important to remember?
A. Decreased blood flow A. Infant can concentrate urine at an adult level
B. Shifting of pressures from right side to the left side of the heart B. The metabolic rate of an infant is slower than in adults
C. Increased PO2 C. Infants have more intracellular water that adult do
D. Increased in oxygen saturation D. Infant have greater body surface area than adults
17. Failure of the Foramen Ovale to close will cause what Congenital Heart Disease? 26. When assessing a child with aspirin overdose, which of the following will be expected?
A. Total anomalous Pulmunary Artery A. Metabolic alkalosis
B. Atrial Septal defect B. Respiratory alkalosis
C. Transposition of great arteries C. Metabolic acidosis
D. Pulmunary Stenosis D. Respiratory acidosis
Situation 4 Children are vulnerable to some minor health problems or injuries hence the nurse 27. Which of the following is not a possible systemic clinical manifestation of severe burns?
should be able to teach mothers to give appropriate home care. A. Growth retardation
18. A mother brought her child to the clinic with nose bleeding. The nurse showed the mother the B. Hypermetabolism
most appropriate position for the child which is: C. Sepsis
A. Sitting up D. Blisters and edema
B. With low back rest 28. When assessing a family for potential child abuse risks, the nurse would observe for which of
C. With moderate back rest the following?
D. Lying semi flat A. Periodic exposure to stress
19. A common problem in children is the inflammation of the middle ear. This is related to the B. Low socio-economic status
malfunctioning of the: C. High level of self esteem
A. Tympanic membrane D. Problematic pregnancies
B. Eustachian tube
29. Which of the following is a possible indicator of Munchausen syndrome by proxy type of child 38. Which of the following would require careful monitoring in the child with ADHD who is
abuse? receiving Methylphenidate (Ritalin)?
A. Bruises found at odd locations, with different stages of healing A. Dental health
B. STD’s and genital discharges B. Mouth dryness
C. Unexplained symptoms of diarrhea, vomiting and apnea with no organic basis C. Height and weight
D. Constant hunger and poor hygiene D. Excessive appetite
30. Which of the following is an inappropriate interventions when caring for a child with HIV? Situation 6 Laura is assigned as the Team Leader during the immunization day at the RHU
A. Teaching family about disease transmission 39. What program for the DOH is launched at 1976 in cooperation with WHO and UNICEF to
B. Offering large amount of fresh fruits and vegetables reduce morbidity and mortality among infants caused by immunizable disease?
C. Encouraging child to perform at optimal level A. Patak day
D. Teach proper hand washing technique B. Immunization day on Wednesday
Situation 5 Agata, 2 years old is rushed to the ER due to cyanosis precipitated by crying. Her C. Expanded program on immunization
mother observed that after playing she gets tired. She was diagnosed with Tetralogy of Fallot. D. Bakuna ng kabtaan
31. The goal of nursing care fro Agata is to: 40. One important principle of the immunization program is based on?
A. Prevent infection A. Statistical occurrence
B. Promote normal growth and development B. Epidemiologic situation
C. Decrease hypoxic spells C. Cold chain management
D. Hydrate adequately D. Surveillance study
32. The immediate nursing intervention for cyanosis of Agata is: 41. The main element of immunization program is one of the following?
A. Call up the pediatrician A. Information, education and communication
B. Place her in knee chest position B. Assessment and evaluation of the program
C. Administer oxygen inhalation C. Research studies
D. Transfer her to the PICU D. Target setting
33. Agata was scheduled for a palliative surgery, which creates anastomosis of the subclavian 42. What does herd immunity means?
artery to the pulmonary artery. This procedure is: A. Interruption of transmission
A. Waterston-Cooley B. All to be vaccinated
B. Raskkind Procedure C. Selected group for vaccination
C. Coronary artery bypass D. Shorter incubation
D. Blalock-Taussig 43. Measles vaccine can be given simultaneously. What is the combined vaccine to be given to
34. Which of the following is not an indicator that Agata experiences separation anxiety brought children starting at 15 months?
about her hospitalization? A. MCG
A. Friendly with the nurse B. MMR
B. Prolonged loud crying, consoled only by mother C. BCG
C. Occasional temper tantrums and always says NO D. BBR
D. Repeatedly verbalizes desire to go home Situation 7: Braguda brought her 5-month old daughter in the nearest RHU because her baby
35. When Agata was brought to the OR, her parents where crying. What would be the most sleeps most of the time, with decreased appetite, has colds and fever for more than a week. The
appropriate nursing diagnosis? physician diagnosed pneumonia.
A. Infective family coping r/t situational crisis 44. Based on this data given by Braguda, you can classify Braguda’s daughter to have:
B. Anxiety r/t powerlessness A. Pneumonia: cough and colds
C. Fear r/t uncertain prognosis B. Severe pneumonia
D. Anticipatory grieving r/t gravity of child’s physical status C. Very severe pneumonia
36. Which of the following respiratory condition is always considered a medical emergency? D. Pneumonia moderate
A. Laryngeotracheobronchitis (LTB) 45. For a 3-month old child to be classified to have Pneumonia (not severe), you would expect to
B. Epiglottitis find RR of:
C. Asthma A. 60 bpm
D. Cystic Fibrosis B. 40 bpm
37. Which of the following statements by the family of a child with asthma indicates a need for C. 70 bpm
additional teaching? D. 50 pbm
A. “We need to identify what things triggers his attacks” 46. You asked Braguda if her baby received all vaccines under EPI. What legal basis is used in
B. “He is to use bronchodilator inhaler before steroid inhaler” implementing the UN’s goal on Universal Child Immunization?
C. “We’ll make sure he avoids exercise to prevent asthma attacks” A. PD no. 996
D. “he should increase his fluid intake regularly to thin secretions” B. PD no. 6
C. PD no. 46
 D. RA 9173 B. Respiratory status
47. Braguda asks you about Vitamin A supplementation. You responded that giving Vitamin A C. Locomotion
starts when the infant reaches 6 months and the first dose is” D. GI function
A. 200,000 “IU” 56. For a child with recurring nephritic syndrome, which of the following areas of potential
B. 100,000 “IU” disturbances should be a prime consideration when planning ongoing nursing care?
C. 500,000 “IU” A. Muscle coordination
D. 10,000 “IU” B. Sexual maturation
48. As part of CARI program, assessment of the child is your main responsibility. You could ask C. Intellectual development
the following question to the mother except: D. Body image
A. “How old is the child?” 57. An inborn error of metabolism that causes premature destruction of RBC?
B. “IS the child coughing? For how long?” A. G6PD
C. “Did the child have chest indrawing?” B. Hemocystinuria
D. “Did the child have fever? For how long?” C. Phenylketonuria
49. A newborn’s failure to pass meconium within 24 hours after birth may indicate which of the D. Celiac Disease
following? 58. Which of the following would be a diagnostic test for Phenylketonuria which uses fresh urine
A. Aganglionic Mega colon mixed with ferric chloride?
B. Celiac disease A. Guthrie Test
C. Intussusception B. Phenestix test
D. Abdominal wall defect C. Beutler’s test
50. The nurse understands that a good snack for a 2 year old with a diagnosis of acute asthma D. Coomb’s test
would be: 59. Dietary restriction in a child who has Hemocystenuria will include which of the following amino
A. Grapes acid?
B. Apple slices A. Lysine
C. A glass of milk B. Methionine
D. A glass of cola C. Isolensine tryptophase
51. Which of the following immunizations would the nurse expect to administer to a child who is D. Valine
HIV (+) and severely immunocomromised? 60. A milk formula that you can suggest for a child with Galactosemia:
A. Varicella A. Lofenalac
B. Rotavirus B. Lactum
C. MMR C. Neutramigen
D. IPV D. Sustagen
52. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to 1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has
assess which of the following? only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the
A. Symmetrical gluteal folds physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the
B. Trendelemburg sign most important aspect of nursing intervention at this time?
C. Ortolani’s sign A. Timing and recording length of contractions.
D. Characteristic limp B. Monitoring.
53. While assessing a male neonate whose mother desires him to be circumcised, the nurse C. Preparing for an emergency cesarean birth.
observes that the neonate’s urinary meatus appears to be located on the ventral surface of the D. Checking the perineum for bulging.
penis. The physician is notified because the nurse would suspect which of the following? 2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Phimosis A. Isolate the client from other patients.
B. Hydrocele B. Maintain a safe environment.
C. Epispadias C. Orient the client to time, place, and person.
D. Hypospadias D. Establish a trusting relationship.
54. When teaching a group of parents about seat belt use, when would the nurse state that the 3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having
child be safely restrained in a regular automobile seatbelt? dryness of the throat. Which of the following would the nurse give to the child?
A. 30 lb and 30 in A. Cola with ice
B. 35 lb and 3 y/o B. Yellow noncitrus Jello
C. 40 lb and 40 in C. Cool cherry Kool-Aid
D. 60 lb and 6 y/o D. A glass of milk
55. When assessing a newborn with cleft lip, the nurse would be alert which of the following will 4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client.
most likely be compromised? The nurse caring to the client provides instructions that the nasal spray must be used exactly as
A. Sucking ability directed to prevent the development of:
 A. Increased nasal congestion. A. Accept the new assignment and complete an incident report describing a shortage of
B. Nasal polyps. nursing staff.
C. Bleeding tendencies. B. Report the incident to the nursing supervisor and request to be floated.
D. Tinnitus and diplopia. C. Report the nursing assessment of the client in transitional labor to the nurse manager
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to and discuss misgivings about the new assignment.
care for the client must institute appropriate precautions. The nurse should: D. Accept the new assignment and provide the best care.
A. Place the client in a private room. 13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to
B. Wear an N 95 respirator when caring for the client. give the discharge teaching regarding the proper care at home. The nurse would anticipate that
C. Put on a gown every time when entering the room. the mother is probably at the:
D. Don a surgical mask with a face shield when entering the room. A. 40 years of age.
6. Which of the following is the most frequent cause of noncompliance to the medical treatment of B. 20 years of age.
open-angle glaucoma? C. 35 years of age.
A. The frequent nausea and vomiting accompanying use of miotic drug. D. 20 years of age.
B. Loss of mobility due to severe driving restrictions. 14. The emergency department has shortage of staff. The nurse manager informs the staff nurse
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. in the critical care unit that she has to float to the emergency department. What should the staff
D. The painful and insidious progression of this type of glaucoma. nurse expect under these conditions?
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a A. The float staff nurse will be informed of the situation before the shift begins.
client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What B. The staff nurse will be able to negotiate the assignments in the emergency department.
would be the initial nursing action? C. Cross training will be available for the staff nurse.
A. Apply pressure directly over the incision site. D. Client assignments will be equally divided among the nurses.
B. Clamp the chest tube near the incision site. 15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is
C. Clamp the chest tube closer to the drainage system. receiving digoxin. Which of the following questions will be asked by the nurse to the parents of
D. Reconnect the chest tube to the Pleurovac. the child in order to assess the client’s risk for digoxin toxicity?
8. Which of the following complications during a breech birth the nurse needs to be alarmed? A. “Has he been exposed to any childhood communicable diseases in the past 2-3
A. Abruption placenta. weeks?”
B. Caput succedaneum. B. “Has he been taking diuretics at home?”
C. Pathological hyperbilirubinemia. C. “Do any of his brothers and sisters have history of cardiac problems?”
D. Umbilical cord prolapse. D. “Has he been going to school regularly?”
9. The nurse is caring to a client diagnosed with severe depression. Which of the following 16. The nurse noticed that the signed consent form has an error. The form states, “Amputation of
nursing approach is important in depression? the right leg” instead of the left leg that is to be amputated. The nurse has administered already
A. Protect the client against harm to others. the preoperative medications. What should the nurse do?
B. Provide the client with motor outlets for aggressive, hostile feelings. A. Call the physician to reschedule the surgery.
C. Reduce interpersonal contacts. B. Call the nearest relative to come in to sign a new form.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep. C. Cross out the error and initial the form.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that D. Have the client sign another form.
the baby may have hypothyroidism when mother states that her baby does not: 17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a
A. Sit up. closed chest drainage system. The fluctuation has stopped, the nurse would:
B. Pick up and hold a rattle. A. Vigorously strip the tube to dislodge a clot.
C. Roll over. B. Raise the apparatus above the chest to move fluid.
D. Hold the head up. C. Increase wall suction above 20 cm H2O pressure.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with D. Ask the client to cough and take a deep breath.
the other staff. The newly hired nurse answers the phone so that the senior nurses may continue 18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the
their conversation. The new nurse does not knowthe physician or the client to whom the order mother in the hospital room is wrong. The nurse determines that two babies were placed in the
pertains. The nurse should: wrong cribs. The most appropriate nursing action would be to:
A. Ask the physician to call back after the nurse has read the hospital policy manual. A. Determine who is responsible for the mistake and terminate his or her employment.
B. Take the telephone order. B. Record the event in an incident/variance report and notify the nursing supervisor.
C. Refuse to take the telephone order. C. Reassure both mothers, report to the charge nurse, and do not record.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order. D. Record detailed notes of the event on the mother’s medical record.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition 19. Before the administration of digoxin, the nurse completes an assessment to a toddler client
complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most
The nurse manager assigned the same nurse to the second client. The nurse feels that the client significant sign of digoxin toxicity?
with hypertension requires one-to-one care. What would be the initial actionof the nurse? A. Tinnitus
B. Nausea and vomiting
 C. Vision problem A. Medicate for pain only when needed.
D. Slowing in the heart rate B. Connect the chest tube to water-seal drainage.
20. Which of the following treatment modality is appropriate for a client with paranoid tendency? C. Notify the physician if the chest drainage exceeds 100mL/hr.
A. Activity therapy. D. Encourage deep breathing and coughing.
B. Individual therapy. 28. The nurse is providing a health teaching to a group of parents regarding Chlamydia
C. Group therapy. trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an
D. Family therapy. intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on A. Discoloration of baby and adult teeth.
prednisone therapy, the nurse should advise the client to: B. Pneumonia in the newborn.
A. Wear sunglasses if exposed to bright light for an extended period of time. C. Snuffles and rhagades in the newborn.
B. Take oral preparations of prednisone before meals. D. Central hearing defects in infancy.
C. Have periodic complete blood counts while on the medication. 29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse.
D. Never stop or change the amount of the medication without medical advice. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the
22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will nurse would be:
be the most appropriate nursing response? A. “Yes, once I tried grass.”
A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have B. “No, I don’t think so.”
frequency associated with fever, pain on voiding, or blood in the urine, call your C. “Why do you want to know that?”
doctor/nurse-midwife. D. “How will my answer help you?”
B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will 30. Which of the following describes a health care team with the principles of participative
go away after the baby comes.” leadership?
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.” A. Each member of the team can independently make decisions regarding the client’s care
D. “Frequency is due to bladder irritation from concentrate urine and is normal in without necessarily consulting the other members.
pregnancy. Increase your daily fluid intake to 3L.” B. The physician makes most of the decisions regarding the client’s care.
23. Which of the following will help the nurse determine that the expression of hostility is useful? C. The team uses the expertise of its members to influence the decisions regarding the
A. Expression of anger dissipates the energy. client’s care.
B. Energy from anger is used to accomplish what needs to be done. D. Nurses decide nursing care; physicians decide medical and other treatment for the
C. Expression intimidates others. client.
D. Degree of hostility is less than the provocation. 31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby.
24. The nurse is providing an orientation regarding case management to the nursing students. Which hormone, normally secreted during the postpartum period, influences both the milk
Which characteristics should the nurse include in the discussion in understanding case ejection reflex and uterine involution?
management? A. Oxytocin.
A. Main objective is a written plan that combines discipline-specific processes used to B. Estrogen.
measure outcomes of care. C. Progesterone.
B. Main purpose is to identify expected client, family and staff performance against the D. Relaxin.
timeline for clients with the same diagnosis. 32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is
C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication responsible for the overall planning, giving and evaluating care during the entire shift. After the
of services, improve resource utilization and decrease cost. shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing
D. Primary goal is to understand why predicted outcomes have not been met and the care delivered via the:
correction of identified problems. A. Primary nursing method.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the B. Case method.
administration of the drug, which nursing action is not correct? C. Functional method.
A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. D. Team method.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy. 33. The ambulance team calls the emergency department that they are going to bring a client
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter. who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate
D. Flush the IV tubing with normal saline before starting phenytoin. emergency care to include assessment for:
26. The pregnant woman visits the clinic for check –up. Which assessment findings will help the A. Gas exchange impairment.
nurse determine that the client is in 8-week gestation? B. Hypoglycemia.
A. Leopold maneuvers. C. Hyperthermia.
B. Fundal height. D. Fluid volume excess.
C. Positive radioimmunoassay test (RIA test). 34. Most couples are using “natural” family planning methods. Most accidental pregnancies in
D. Auscultation of fetal heart tones. couples preferred to use this method have been related to unprotected intercourse before
27. Which of the following nursing intervention is essential for the client who had ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected
pneumonectomy? intercourse during the preovulatory period?
 A. Ovum viability. D. Wire cutters.
B. Tubal motility. 43. A mother is in the third stage of labor. Which of the following signs will help the nurse
C. Spermatozoal viability. determine the signs of placental separation?
D. Secretory endometrium. A. The uterus becomes globular.
35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station B. The umbilical cord is shortened.
saying, “I am having difficulty in sleeping.” What is the best nursing response to the client? C. The fundus appears at the introitus.
A. “I’ll give you a sleeping pill to help you get more sleep now.” D. Mucoid discharge is increased.
B. “Perhaps you’d like to sit here at the nurse’s station for a while.” 44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to
C. “Would you like me to show you where the bathroom is?” the physician?
D. “What woke you up?” A. 3+ peripheral pulses.
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, B. Change in level of consciousness and headache.
her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of C. Occasional dysrhythmias.
maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts D. Heart rate of 100/bpm.
100 beats per minute. The immediate nursing action is to: 45. A client who undergone left nephrectomy has a large flank incision. Which of the following
A. Start oxygen by mask to reduce fetal distress. nursing action will facilitate deep breathing and coughing?
B. Examine the woman for signs of a prolapsed cord. A. Push fluid administration to loosen respiratory secretions.
C. Turn the woman on her left side to increase placental perfusion. B. Have the client lie on the unaffected side.
D. Take the woman’s radial pulse while still auscultating the FHR. C. Maintain the client in high Fowler’s position.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications D. Coordinate breathing and coughing exercise with administration of analgesics.
like: 46. The community nurse is teaching the group of mothers about the cervical mucus method of
A. Antihistamines. natural family planning. Which characteristics are typical of the cervical mucus during the “fertile”
B. NSAIDs. period of the menstrual cycle?
C. Antacids. A. Absence of ferning.
D. Salicylates. B. Thin, clear, good spinnbarkeit.
38. A male client is brought to the emergency department due to motor vehicle accident. While C. Thick, cloudy.
monitoring the client, the nurse suspects increasing intracranial pressure when: D. Yellow and sticky.
A. Client is oriented when aroused from sleep, and goes back to sleep immediately. 47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care
B. Blood pressure is decreased from 160/90 to 110/70. unit. The nurse placed the client in a semi-Fowler’s position primarily to:
C. Client refuses dinner because of anorexia. A. Facilitate movement and reduce complications from immobility.
D. Pulse is increased from 88-96 with occasional skipped beat. B. Fully aerate the lungs.
39. The nurse is conducting a lecture to a class of nursing students about advance directives to C. Splint the wound.
preoperative clients. Which of the following statement by the nurse js correct? D. Promote drainage and prevent subdiaphragmatic abscesses.
A. “The spouse, but not the rest of the family, may override the advance directive.” 48. Which of the following will best describe a management function?
B. “An advance directive is required for a “do not resuscitate” order.” A. Writing a letter to the editor of a nursing journal.
C. “A durable power of attorney, a form of advance directive, may only be held by a blood B. Negotiating labor contracts.
relative.” C. Directing and evaluating nursing staff members.
D. “The advance directive may be enforced even in the face of opposition by the spouse.” D. Explaining medication side effects to a client.
40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the 49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye
outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention? drops. The nurse is correct in advising the parents to place the drops:
A. Tell the client that he cannot bang on the door. A. In the middle of the lower conjunctival sac of the infant’s eye.
B. Ignore this behavior. B. Directly onto the infant’s sclera.
C. Escort the client going back into the room. C. In the outer canthus of the infant’s eye.
D. Ask the client to move away from the door. D. In the inner canthus of the infant’s eye.
41. Which of the following action is an accurate tracheal suctioning technique? 50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the
A. 25 seconds of continuous suction during catheter insertion. following findings will help the nurse that there is internal bleeding?
B. 20 seconds of continuous suction during catheter insertion. A. Frank blood on the clothing.
C. 10 seconds of intermittent suction during catheter withdrawal. B. Thirst and restlessness.
D. 15 seconds of intermittent suction during catheter withdrawal. C. Abdominal pain.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most D. Confusion and altered of consciousness.
important thing that must be ready at the bedside is: 51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the
A. Suture set. skin of the newborn is dry and flaking and there are several areas of an apparent macular rash.
B. Tracheostomy set. The nurse charts this as:
C. Suction equipment. A. Icterus neonatorum
 B. Multiple hemangiomas 59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00
C. Erythema toxicum AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to
D. Milia 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to
52. The client is brought to the emergency department because of serious vehicle accident. After keep in mind in planning nursing intervention for this client?
an hour, the client has been declared brain dead. The nurse who has been with the client must A. Depression underlines ritualistic behavior.
now talk to the family about organ donation. Which of the following consideration is necessary? B. Fear and tensions are often expressed in disguised form through symbolic processes.
A. Include as many family members as possible. C. Ritualistic behavior makes others uncomfortable.
B. Take the family to the chapel. D. Unmet needs are discharged through ritualistic behavior.
C. Discuss life support systems. 60. The nurse assesses the health condition of the female client. The client tells the nurse that
D. Clarify the family’s understanding of brain death. she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse
53. The nurse is teaching exercises that are good for pregnant women increasing tone and understands that, women who tend to delay seeking medical advice after discovering the disease
fitness and decreasing lower backache. Which of the following should the nurse exclude in the are displaying what common defense mechanism?
exercise program? A. Intellectualization.
A. Stand with legs apart and touch hands to floor three times per day. B. Suppression.
B. Ten minutes of walking per day with an emphasis on good posture. C. Repression.
C. Ten minutes of swimming or leg kicking in pool per day. D. Denial.
D. Pelvic rock exercise and squats three times a day. 61. Which of the following situations cannot be delegated by the registered nurse to the nursing
54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse assistant?
taking care of the client knows that the primary treatment goal is to: A. A postoperative client who is stable needs to ambulate.
A. Provide distraction. B. Client in soft restraint who is very agitated and crying.
B. Support but limit the behavior. C. A confused elderly woman who needs assistance with eating.
C. Prohibit the behavior. D. Routine temperature check that must be done for a client at end of shift.
D. Point out the behavior. 62. In the admission care unit, which of the following client would the nurse give immediate
55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma: attention?
A. When the client is able to begin self-care procedures. A. A client who is 3 days postoperative with left calf pain.
B. 24 hours later, when the swelling subsided. B. A client who is postoperative hip pinning who is complaining of pain.
C. In the operating room after the ileostomy procedure. C. New admitted client with chest pain.
D. After the ileostomy begins to function. D. A client with diabetes who has a glucoscan reading of 180.
56. A female client who has a 28-day menstrual cycle asks the community health nurse when she 63. A couple seeks medical advice in the community health care unit. A couple has been unable
get pregnant during her cycle. What will be the best nursing response? to conceive; the man is being evaluated for possible problems. The physician ordered semen
A. It is impossible to determine the fertile period reliably. So it is best to assume that a analysis. Which of the following instructions is correct regarding collection of a sperm specimen?
woman is always fertile. A. Collect a specimen at the clinic, place in iced container, and give to laboratory
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours personnel immediately.
and the sperm live for about 72 hours. The fertile period would be approximately B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
between day 11 and day 15. C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours immediately.
and the sperm live for about 24 hours. The fertile period would be approximately D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
between day 13 and 17. 64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. sign of preterm labor. The nurse expects that the drug will:
The fertile period is between day 20 and the beginning of the next period. A. Treat infection.
57. Which of the following statement describes the role of a nurse as a client advocate? B. Suppress labor contraction.
A. A nurse may override clients’ wishes for their own good. C. Stimulate the production of surfactant.
B. A nurse has the moral obligation to prevent harm and do well for clients. D. Reduce the risk of hypertension.
C. A nurse helps clients gain greater independence and self-determination. 65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be
D. A nurse measures the risk and benefits of various health situations while factoring in implemented before starting the procedures?
cost. A. Suction the trachea and mouth.
58. A community health nurse is providing a health teaching to a woman infected with herpes B. Have the obdurator available.
simplex 2. Which of the following health teaching must the nurse include to reduce the chances of C. Encourage deep breathing and coughing.
transmission of herpes simplex 2? D. Do a pulse oximetry reading.
A. “Abstain from intercourse until lesions heal.” 66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:
B. “Therapy is curative.” A. Gloves are worn when handling the client’s tissue, excretions, and linen.
C. “Penicillin is the drug of choice for treatment.” B. Both client and attending nurse must wear masks at all times.
D. “The organism is associated with later development of hydatidiform mole.
 C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in A. Be drawn in the same syringe and given in one injection.
cough and tissue techniques. B. Be mixed and inject in the same sites.
D. Full isolation; that is, caps and gowns are required during the period of contagion. C. Not be mixed and the nurse must give three injections in three sites.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the D. Be mixed and the nurse must give the injection in three sites.
condition of his wife. How should the nurse respond to the husband? 75. A female client with cancer has radium implants. The nurse wants to maintain the implants in
A. Find out what information he already has. the correct position. The nurse should position the client:
B. Suggest that he discuss it with his wife. A. Flat in bed.
C. Refer him to the doctor. B. On the side only.
D. Refer him to the nurse in charge. C. With the foot of the bed elevated.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the D. With the head elevated 45-degrees (semi-Fowler’s).
nurse of stealing them. Which is the most therapeutic approach to this client? 76. The nurse wants to know if the mother of a toddler understands the instructions regarding the
A. Divert the client’s attention. administration of syrup of ipecac. Which of the following statement will help the nurse to know
B. Listen without reinforcing the client’s belief. that the mother needs additional teaching?
C. Inject humor to defuse the intensity. A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
D. Logically point out that the client is jumping to conclusions. B. “I’ll give the medicine if my child gets into some aspirin.”
69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding C. “I’ll give the medicine if my child gets into some plant bulbs.”
prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in D. “I’ll give the medicine if my child gets into some vitamin pills.”
the instruction to empty the urine pouch: 77. To assess if the cranial nerve VII of the client was damaged, which changes would not be
A. Every 3-4 hours. expected?
B. Every hour. A. Drooling and drooping of the mouth.
C. Twice a day. B. Inability to open eyelids on operative side.
D. Once before bedtime. C. Sagging of the face on the operative side.
70. Which telephone call from a student’s mother should the school nurse take care of at once? D. Inability to close eyelid on operative side.
A. A telephone call notifying the school nurse that the child’ pediatrician has informed the 78. The community health nurse makes a home visit to a family. During the visit, the nurse
mother that the child will need cardiac repair surgery within the next few weeks. observes that the mother is beating her child. What is the priority nursing intervention in this
B. A telephone call notifying the school nurse that the child’s pediatrician has informed the situation?
mother that the child has head lice. A. Assess the child’s injuries.
C. A telephone call notifying the school nurse that a child has a temperature of 102ºF and B. Report the incident to protective agencies.
a rash covering the trunk and upper extremities of the body. C. Refer the family to appropriate support group.
D. A telephone call notifying the school nurse that a child underwent an emergency D. Assist the family to identify stressors and use of other coping mechanisms to prevent
appendectomy during the previous night. further incidents.
71. Which of the following signs and symptoms that require immediate attention and may indicate 79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in
most serious complications during pregnancy? giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a
A. Severe abdominal pain or fluid discharge from the vagina. newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing
B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus. assistant:
C. Fatigue, nausea, and urinary frequency at any time during pregnancy. A. Always, as a representative of the institution.
D. Ankle edema, enlarging varicosities, and heartburn. B. Always, because nurses who supervise less-trained individuals are responsible for their
72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes mistakes.
slightly cyanotic. What is the initial nursing action? C. If the nurse failed to determine whether the nursing assistant was competent to take
A. Elevate his head to promote gravity drainage of secretions. care of the client.
B. Wrap him in another blanket, to reduce heat loss. D. Only if the nurse agreed that the newborn could be fed formula.
C. Stimulate him to cry,, to increase oxygenation. 80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is
D. Aspirate his mouth and nose with bulb syringe. encouraged to the client. the primary reason for this is to:
73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse A. Reduce the size of existing stones.
needs to have knowledge of which psychodynamic principle? B. Prevent crystalline irritation to the ureter.
A. The symptoms of a somatoform disorder are an attempt to adjust to painful life C. Reduce the size of existing stones
situations or to cope with conflicting sexual, aggressive, or dependent feelings. D. Increase the hydrostatic pressure in the urinary tract.
B. The major fundamental mechanism is regression. 81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for
C. The client’s symptoms are imaginary and the suffering is faked. about 6 months. They are concerned that one or both of them may be infertile. What is the best
D. An extensive, prolonged study of the symptoms will be reassuring to the client, who advice the nurse could give to the couple?
seeks sympathy, attention and love. A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are
74. An infant is brought to the health care clinic for three immunizations at the same time. The in their mid-30s. Eat well, exercise, and avoid stress.”
nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should: B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.”
 C. “Consult a fertility specialist and start testing before you get any older.” A. 1 g
D. “Have sex as often as you can, especially around the time of ovulation, to increase your B. 500 mg
chances of pregnancy.” C. 250 mg
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine D. 125 mg
clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The 90. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric
best response by the nurse is: history will help the nurse suspects dysfunctional labor in the current pregnancy?
A. “It provides a way to see if you are passing any protein in your urine.” A. Total time of ruptured membranes was 24 hours with the second birth.
B. “It tells how well the kidneys filter wastes from the blood.” B. First labor lasting 24 hours.
C. “It tells if your renal insufficiency has affected your heart.” C. Uterine fibroid noted at time of cesarean delivery.
D. “The test measures the number of particles the kidney filters.” D. Second birth by cesarean for face presentation.
83. The nurse observes the female client in the psychiatric ward that she is having a hard time 91. The nurse is planning to talk to the client with an antisocial personality disorder. What would
sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night be the most therapeutic approach?
because of fear of dying.” What is the best initial nursing response? A. Provide external controls.
A. “It must be frightening for you to feel that way. Tell me more about it.” B. Reinforce the client’s self-concept.
B. “Don’t worry, you won’t die. You are just here for some test.” C. Give the client opportunities to test reality.
C. “Why are you afraid of dying?” D. Gratify the client’s inner needs.
D. “Try to sleep. You need the rest before tomorrow’s test.” 92. The nurse is teaching a group of women about fertility awareness, the nurse should
84. In the hospital lobby, the registered nurse overhears a two staff members discussing about emphasize that basal body temperature:
the health condition of her client. What would be the appropriate action for the registered nurse to A. Can be done with a mercury thermometer but no a digital one.
take? B. The average temperature taken each morning.
A. Join in the conversation, giving her input about the case. C. Should be recorded each morning before any activity.
B. Ignore them, because they have the right to discuss anything they want to. D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
C. Tell them it is not appropriate to discuss such things. 93. The nursing applicant has given the chance to ask questions during a job interview at a local
D. Report this incident to the nursing supervisor. hospital. What should be the most important question to ask that can increase chances of
85. The client has had a right-sided cerebrovascular accident. In transferring the client from the securing a job offer?
wheelchair to bed, in what position should a client be placed to facilitate safe transfer? A. Begin with questions about client care assignments, advancement opportunities, and
A. Weakened (L) side of the cient next to bed. continuing education.
B. Weakened (R) side of the client next to bed. B. Decline to ask questions, because that is the responsibility of the interviewer.
C. Weakened (L) side of the client away from bed. C. Ask as many questions about the facility as possible.
D. Weakened (R) side of the cient away from bed. D. Clarify information regarding salary, benefits, and working hours first, because this will
86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy help in deciding whether or not to take the job.
should be avoided to be in the child’s bed? 94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during
A. A toy gun. pregnancy. The nurse takes into account that the developing fetus is most vulnerable to
B. A stuffed animal. environment teratogens that cause malformation during:
C. A ball. A. The entire pregnancy.
D. Legos. B. The third trimester.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be C. The first trimester.
given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin: D. The second trimester.
A. Minimizes discomfort from “afterpains.” 95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing
B. Suppresses lactation. response would be:
C. Promotes lactation. A. Silence.
D. Maintains uterine tone. B. “Where’s the bug? I’ll kill it for you.”
88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely C. “I don’t see a bug in your bed, but you seem afraid.”
behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been D. “You must be seeing things.”
reported to the nurse manager several times, but no changes observed. The nurse should: 96. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right
A. Continue to report observations of unusual behavior until the problem is resolved. side. Which of the following is the most likely cause of it?
B. Consider that the obligation to protect the patient from harm has been met by the prior A. Beginning of labor.
reports and do nothing further. B. Bladder infection.
C. Discuss the situation with friends who are also nurses to get ideas . C. Constipation.
D. Approach the partner of this medical staff member with these concerns. D. Tension on the round ligament.
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The 97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in
recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice
can be safely administered to this child? when:
 A. The nurse stops to render emergency aid and leaves before the ambulance arrives. C. Place the tape measure under the infants head, wrap around the occiput, and measure
B. The nurse acts in an emergency at his or her place of employment. just above the eyes
C. The nurse refuses to stop for an emergency outside of the scope of employment. D. Place the tape measure at the back of the infant’s head, wrap around across the ears,
D. The nurse is grossly negligent at the scene of an emergency.
and measure across the infant’s mouth.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for
this client, which nursing care is least likely to be done? 5) A postpartum nurse is providing instructions to the mother of a newborn infant with
A. Deep-tendon reflexes once per shift. hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate
B. Vital signs and FHR and rhythm q4h while awake. instructions to the mother?
C. Absolute bed rest. A. Switch to bottle feeding the baby for 2 weeks
D. Daily weight. B. Stop the breast feedings and switch to bottle-feeding permanently
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the C. Feed the newborn infant less frequently
condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute.
D. Continue to breast-feed every 2-4 hours
What would be the initial nursing action?
A. Burp the newborn. 6) A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is
B. Stop the feeding. exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress
C. Continue the feeding. syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse
D. Notify the physician. would prepare to administer this therapy by:
100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The A. Subcutaneous injection
nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my B. Intravenous injection
appointment,” and calling the nurse by the wrong name. The nurse suspects:
C. Instillation of the preparation into the lungs through an endotracheal tube
A. Panic reaction.
B. Medication overdose. D. Intramuscular injection
C. Toxic reaction to an antibiotic. 7) A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs.
D. Delirium tremens. Which of the following assessment findings would the nurse expect to note during the
1) A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, assessment of this newborn?
the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Sleepiness
A. Warming the crib pad B. Cuddles when being held
B. Turning on the overhead radiant warmer C. Lethargy
C. Closing the doors to the room D. Incessant crying
D. Drying the infant in a warm blanket 8) A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the
2) A nurse is assessing a newborn infant following circumcision and notes that the nurse why her newborn infant needs the injection. The best response by the nurse would be:
circumcised area is red with a small amount of bloody drainage. Which of the following nursing A. “You infant needs vitamin K to develop immunity.”
actions would be most appropriate? B. “The vitamin K will protect your infant from being jaundiced.”
A. Document the findings C. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from
B. Contact the physician abnormal bleeding.”
C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. “Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in
D. Reinforce the dressing the bowel.”
3) A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress 9) A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-
syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the
possibility of this syndrome? nurse’s highest priority should be to:
A. Hypotension and Bradycardia A. Connect the resuscitation bag to the oxygen outlet
B. Tachypnea and retractions B. Turn on the apnea and cardiorespiratory monitors
C. Acrocyanosis and grunting C. Set up the intravenous line with 5% dextrose in water
D. The presence of a barrel chest with grunting D. Set the radiant warmer control temperature at 36.5* C (97.6*F)
4) A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is 10) Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which
preparing to measure the head circumference of the infant. The nurse would most appropriately: muscle site?
A. Wrap the tape measure around the infant’s head and measure just above the eyebrows. A. Deltoid
B. Place the tape measure under the infants head at the base of the skull and wrap around B. Triceps
to the front just above the eyes C. Vastus lateralis
 D. Biceps D. Supplementing breastfeeding with glucose water during the first 24 hours
11) A nursing instructor asks a nursing student to describe the procedure for administering 19) A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are
erythromycin ointment into the eyes if a neonate. The instructor determines that the student caused by retained sebaceous secretions. When charting this observation, the nurse identifies it
needs to research this procedure further if the student states: as:
A. “I will cleanse the neonate’s eyes before instilling ointment.” A. Milia
B. “I will flush the eyes after instilling the ointment.” B. Lanugo
C. “I will instill the eye ointment into each of the neonate’s conjunctival sacs within one C. Whiteheads
hour after birth.” D. Mongolian spots
D. “Administration of the eye ointment may be delayed until an hour or so after birth so that 20) When newborns have been on formula for 36-48 hours, they should have a:
eye contact and parent-infant attachment and bonding can occur.” A. Screening for PKU
12) A baby is born precipitously in the ER. The nurses initial action should be to: B. Vitamin K injection
A. Establish an airway for the baby C. Test for necrotizing enterocolitis
B. Ascertain the condition of the fundus D. Heel stick for blood glucose level
C. Quickly tie and cut the umbilical cord 21) The nurse decides on a teaching plan for a new mother and her infant. The plan should
D. Move mother and baby to the birthing unit include:
13) The primary critical observation for Apgar scoring is the: A. Discussing the matter with her in a non-threatening manner
A. Heart rate B. Showing by example and explanation how to care for the infant
B. Respiratory rate C. Setting up a schedule for teaching the mother how to care for her baby
C. Presence of meconium D. Supplying the emotional support to the mother and encouraging her independence
D. Evaluation of the Moro reflex 22) Which action best explains the main role of surfactant in the neonate?
14) When performing a newborn assessment, the nurse should measure the vital signs in the A. Assists with ciliary body maturation in the upper airways
following sequence: B. Helps maintain a rhythmic breathing pattern
A. Pulse, respirations, temperature C. Promotes clearing mucus from the respiratory tract
B. Temperature, pulse, respirations D. Helps the lungs remain expanded after the initiation of breathing
C. Respirations, temperature, pulse 23) While assessing a 2-hour old neonate, the nurse observes the neonate to have
D. Respirations, pulse, temperature acrocyanosis. Which of the following nursing actions should be performed initially?
15) Within 3 minutes after birth the normal heart rate of the infant may range between: A. Activate the code blue or emergency system
A. 100 and 180 B. Do nothing because acrocyanosis is normal in the neonate
B. 130 and 170 C. Immediately take the newborn’s temperature according to hospital policy
C. 120 and 160 D. Notify the physician of the need for a cardiac consult
D. 100 and 130 24) The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?
16) The expected respiratory rate of a neonate within 3 minutes of birth may be as high as: A. Anemia
A. 50 B. Hypoglycemia
B. 60 C. Nitrogen loss
C. 80 D. Thrombosis
D. 100 25) A client with group AB blood whose husband has group O has just given birth. The major
17) The nurse is aware that a healthy newborn’s respirations are: sign of ABO blood incompatibility in the neonate is which complication or test result?
A. Regular, abdominal, 40-50 per minute, deep A. Negative Coombs test
B. Irregular, abdominal, 30-60 per minute, shallow B. Bleeding from the nose and ear
C. Irregular, initiated by chest wall, 30-60 per minute, deep C. Jaundice after the first 24 hours of life
D. Regular, initiated by the chest wall, 40-60 per minute, shallow D. Jaundice within the first 24 hours of life
18) To help limit the development of hyperbilirubinemia in the neonate, the plan of care should 26) A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which
include: physical finding is expected?
A. Monitoring for the passage of meconium each shift A. A sleepy, lethargic baby
B. Instituting phototherapy for 30 minutes every 6 hours B. Lanugo covering the body
C. Substituting breastfeeding for formula during the 2nd day after birth C. Desquamation of the epidermis
 D. Vernix caseosa covering the body C. Nevus flammeus
27) After reviewing the client’s maternal history of magnesium sulfate during labor, which D. Vernix
condition would the nurse anticipate as a potential problem in the neonate? 35) Which condition or treatment best ensures lung maturity in an infant?
A. Hypoglycemia A. Meconium in the amniotic fluid
B. Jitteriness B. Glucocorticoid treatment just before delivery
C. Respiratory depression C. Lecithin to sphingomyelin ratio more than 2:1
D. Tachycardia D. Absence of phosphatidylglycerol in amniotic fluid
28) Neonates of mothers with diabetes are at risk for which complication following birth? 36) When performing nursing care for a neonate after a birth, which intervention has the highest
A. Atelectasis nursing priority?
B. Microcephaly A. Obtain a dextrostix
C. Pneumothorax B. Give the initial bath
D. Macrosomia C. Give the vitamin K injection
29) By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse D. Cover the neonates head with a cap
is preventing which type of heat loss? 37) When performing an assessment on a neonate, which assessment finding is most
A. Conduction suggestive of hypothermia?
B. Convection A. Bradycardia
C. Evaporation B. Hyperglycemia
D. Radiation C. Metabolic alkalosis
30) A neonate has been diagnosed with caput succedaneum. Which statement is correct about D. Shivering
this condition? 38) A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is
A. It usually resolves in 3-6 weeks expected during an examination if this neonate?
B. It doesn’t cross the cranial suture line A. Abundant lanugo
C. It’s a collection of blood between the skull and the periosteum B. Absence of sole creases
D. It involves swelling of tissue over the presenting part of the presenting head C. Breast bud of 1-2 mm in diameter
31) The most common neonatal sepsis and meningitis infections seen within 24 hours after birth D. Leathery, cracked, and wrinkled skin
are caused by which organism? 39) A healthy term neonate born by C-section was admitted to the transitional nursery 30
A. Candida albicans minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of
B. Chlamydia trachomatis 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which
C. Escherichia coli action should the nurse take?
D. Group B beta-hemolytic streptococci A. Wrap the neonate warmly and place her in an open crib
32) When attempting to interact with a neonate experiencing drug withdrawal, which behavior B. Administer an oral glucose feeding of 10% dextrose in water
would indicate that the neonate is willing to interact? C. Increase the temperature setting on the radiant warmer
A. Gaze aversion D. Obtain an order for IV fluid administration
B. Hiccups 40) Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)?
C. Quiet alert state A. Hypoactivity
D. Yawning B. High birth weight
33) When teaching umbilical cord care to a new mother, the nurse would include which C. Poor wake and sleep patterns
information? D. High threshold of stimulation
A. Apply peroxide to the cord with each diaper change 1.A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size
B. Cover the cord with petroleum jelly after bathing of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational
C. Keep the cord dry and open to air trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
D. Wash the cord with soap and water each day during a tub bath A. an empty gestational sac.
34) A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which B. grapelike clusters.
correctly describes this finding? C. a severely malformed fetus.
A. Lanugo D. an extrauterine pregnancy.
B. Milia 2.Of the following terms, which is used to refer to a type of gestational trophoblastic neoplasm?
 A. Hydatidiform mole C. sperm fertilizes empty egg
B. Dermoid cyst D. two sperm fertilize one egg
C. Doderlein’s bacilli E. no fetus is formed
D. Bartholin’s cyst
3. Which of the following signs will require a mother to seek immediate medical attention? 1.Which of the following is described as premature separation of a normally implanted placenta
A. When the first fetal movement is felt during the second half of pregnancy, usually with severe hemorrhage?
B. No fetal movement is felt on the 6th month A. Placenta previa
C. Mild uterine contraction B. Ectopic pregnancy
D. Slight dyspnea on the last month of gestation C. Incompetent cervix
4. Which of the following signs and symptoms will most likely make the nurse suspect that the D. Abruptio placentae
patient is having hydatidiform mole? 2. Check all that apply to incompetent cervix:
A. Slight bleeding A. occurs in 2nd trimester
B. Passage of clear vesicular mass per vagina B. dilatation is painless and bloodless
C. Absence of fetal heart beat C. shortened cervical length
D. Enlargement of the uterus D. minimal symptoms
5. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the 3. Risk factors of incompetent cervix:
umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. A. history of incompetent cervix
Which of the following is the most possible diagnosis of this condition? B. anatomic abnormalities
A. Hydatidiform mole C. cervical conization or surgeries
B. Missed abortion D. DES exposure
C. Pelvic inflammatory disease E. damaged cervix
D. Ectopic pregnancy 4. The best time to treat incompetent cervix is between ___ and ____ weeks of pregnancy before
6. Which of the following symptoms occurs with a hydatidiform mole? the dilatation occurs.
A. Heavy, bright red bleeding every 21 days A. 12, 18
B. Fetal cardiac motion after 6 weeks gestation B. 10,12
C. Benign tumors found in the smooth muscle of the uterus C. 2,3
D. “Snowstorm” pattern on ultrasound with no fetus or gestational sac D. 18,25
7. Molar pregnancies may be complete, partial, invasive, or malignant. 5. Restriction of activities and cervical cerclage are the treatments for __________.
A. True A. Abruptio Placenta
B. False B. Placenta Previa
8. Risk factor of trophoblastic disease: C. Incompetent Cervix
A. over 40 D. H-mole
B. low economic status 1. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the
C. previous molar pregnancy following signs, if noted in the mother, would be an early sign of excessive blood loss?
D. women living in far eastern countries A. A temperature of 100.4*F
E. diets deficient in protein and folic acid B. An increase in the pulse from 88 to 102 BPM
F. 30 or younger C. An increase in the respiratory rate from 18 to 22 breaths per minute
9. Check all that apply to the treatment of molar pregnancies: D. A blood pressure change from 130/88 to 124/80 mm Hg
A. frequent follow ups 2. Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration
B. evacuation of molar pregnancy of these medications, the priority nursing assessment is to check the:
C. radiation A. Amount of lochia
D. possible chemotherapy B. Blood pressure
E. serial hCG levels C. Deep tendon reflexes
10.Check all that cause a “complete” molar pregnancy: D. Uterine tone
A. placenta grows and produces hCG
B. some fetal components
3. Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the B. Forceps delivery
medication(s), the nurse contacts the health provider who prescribed the medication(s) in which C. Schultz delivery
of the following conditions is documented in the client’s medical history? D. Weak bearing down efforts
A. Peripheral vascular disease 2. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-section
B. Hypothyroidism and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse
C. Hypotension palpates tetanic contractions, the client again complains of severe pain. After the client vomits,
D. Type 1 diabetes she states that the pain is better and then passes out. Which is the probable cause of her signs
4. Which of the following complications is most likely responsible for a delayed postpartum and symptoms?
hemorrhage? A. Hysteria compounded by the flu
A. Cervical laceration B. Placental abruption
B. Clotting deficiency C. Uterine rupture
C. Perineal laceration D. Dysfunctional labor
D. Uterine subinvolution 3. During the period of induction of labor, a client should be observed carefully for signs of:
5. Which of the following circumstances is most likely to cause uterine atony and lead to PP A. Severe pain
hemorrhage? B. Uterine tetany
A. Hypertension C. Hypoglycemia
B. Cervical and vaginal tears D. Umbilical cord prolapse
C. Urine retention 4. At what stage of labor is the mother is advised to bear down?
D. Endometritis A. When the mother feels the pressure at the rectal area
6. Which measure would be least effective in preventing postpartum hemorrhage? B. During a uterine contraction
A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered C. In between uterine contraction to prevent uterine rupture
B. Encourage the woman to void every 2 hours D. Anytime the mother feels like bearing down
C. Massage the fundus every hour for the first 24 hours following birth 5. When uterine rupture occurs, which of the following would be the priority?
D. Teach the woman the importance of rest and nutrition to enhance healing A. Limiting hypovolemic shock
7. To be considered a PPH, what would the estimated blood loss have to be for a C-section? B. Obtaining blood specimens
A. < 550 ML C. Instituting complete bed rest
B. > 600 ML D. Inserting a urinary catheter
C. > 1000 ML 1.Once a fetus is infected, it more more susceptible to infection due to its poor immunity and lack
D. < 900 ML of synthesis of what antibody?
8. What types of trauma during labour and birth would lead to PPH risk? A. IgA
A. Instrumental assisted birth (vacuum or forceps) B. IgD
B. C-Section C. IgG
C. Lacerations of the cervix or vaginal wall D. IgM
D. All of the above 2. Molecules that can cause cellular defects in growth, i.e. induce fetal malformations, are known
9. Atonic bleeding is due to a lack of tone in the uterus. as
A. True A. secretagogues
B. False B. teratogens
10. The 4 “T’s” of PPH are: C. hematotrophic
1. Trauma 2.Toxins 3.Travel 4.Tissue 5.Threads 6.Thrombin 7.Tears 8.Tone D. cytopathogenic
A. 1, 4, 6 & 8 3. A distinguishing factor between viral teratogens (rubella) and other teratogens (drugs,
B. 1, 5 7 & 8 radiation) would be that
C. 1, 2, 3 & 6 A. only viral teratogens cause retarded fetal growth
D. 3, 4, 5 & 6 B. fetal death is only a possibility with other teratogens, not viral
1. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse C. maternal effects are only seen with viral teratogens
would monitor the client closely for the risk of uterine rupture if which of the following occurred? D. genetic factors are not present with viral teratogens
A. Hypotonic contractions
4. Primary infection of the mother, rather than re-activation, tends to have a worse fetal A. Prepregnancy BMI of 18.5
consequence. B. ½ ppd smoker during pregnancy
A. True C. History of preterm labor
B. False D. Previous cesarean delivery
5. A fetus is particularly susceptible to rubella infection when maternal infection occurs during 3. Infection in the uterus may cause PROM and may also be a complication following PROM.
what stage of pregnancy? A. True
A. 1st trimester B. False
B. 2nd trimester 4. PROM may occur if the uterus is over-stretched by malpresentation of the fetus, multiple
C. 3rd trimester pregnancy or excess amniotic fluid.
D. susceptibility unknown A. True
6. Congenital rubella is associated with the development of what clinical condition in 80% of B. False
those infants infected? 5. Cervical incompetence in combination with PROM can be a cause of umbilical cord prolapse.
A. blindness A. True
B. deafness B. False
C. obesity 6. The fetal membranes are so strong that blunt trauma to the abdomen is unlikely to cause
D. diabetes mellitus PROM.
7. What antibody, produced by the fetus, can be detected in the cord blood of an infant infected A. True
with the rubella virus? B. False
A. IgA 7. Hypoxia and asphyxia of the woman in labour is a common complication of prolonged PROM.
B. IgD A. True
C. IgG B. False
D. IgM 8. A sudden gush of clear watery fluid from the vagina is always seen in cases of PROM.
8. Congenital rubella is completely preventable by A. True
A. isolation B. False
B. vaccination 9. Which of the following would the nurse Sandra most likely expect to find when assessing a
C. having a superb immune system pregnant client with abruption placenta?
9. A primary CMV infection occurring during the first trimester is associated with sensorineural A. Excessive vaginal bleeding
hearing loss, more specifically associated with what cranial nerve? B. Rigid, boardlike abdomen
A. CN IV C. Titanic uterine contractions
B. CN V D. Premature rupture of membranes
C. CN VI 10. Which of the following increases the risk of placental abruption?
D. CN VIII A. Age < 35 years
10.Clinical features such as hepatosplenomegaly, skin and mucosal lesions, and a saddle- B. Gestational diabetes
shaped nose are associated with what congenital infection? C. Previous placental abruption
A. congenital rubella D. Strenuous exercise
B. congenital CMV 1. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will
C. congenital syphilis most likely be treated with:
D. congenital HIV A. Magnesium sulfate
1. The nurse is reviewing orders on a patient admitted for preterm premature rupture of B. Calcium gluconate
membranes. Which physician order will the nurse question? C. Dinoprostone (Prostin E.)
A. Perform a vaginal exam every shift D. Bromocrystine (Pardel)
B. Monitor maternal temperature every 4 hours 2. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the
C. Continuous fetal heart rate monitoring umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated.
D. Ampicillin 1 gm IVPB q 6 hours Which of the following is the most possible diagnosis of this condition?
2.When considering assessment history of a G3 P2 admitted for preterm labor, which risk factor A. Hydatidiform mole
in the woman’s history places her at greatest risk for preterm labor? B. Missed abortion
 C. Pelvic inflammatory disease D. complete
D. Ectopic pregnancy E. threatened
3. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal 9. Embryo or fetus dies but isn’t expelled. It’s often discovered by the physician when no FHT is
bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the present. Fetus must be expelled within 6wks or DIC and/or infections can occur.
client’s complaint of vaginal bleeding? A. habitual
A. Placenta previa B. missed
B. Abruptio placentae C. incomplete
C. Ectopic pregnancy D. inevitable
D. Spontaneous abortion E. threatened
4. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she 10. All of the products of conception are expelled.
has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse A. inevitable
instructs the client regarding management of care. Which statement, if made by the client, B. complete
indicates a need for further education? C. threatened
A. “I will maintain strict bedrest throughout the remainder of pregnancy.” D. habitual
B. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following E. missed
the last evidence of bleeding.” 1.The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would
C. “I will count the number of perineal pads used on a daily basis and note the amount and observe which of the following if stoma prolapse occurred?
color of blood on the pad.” A. Sunken and hidden stoma
D. “I will watch for the evidence of the passage of tissue.” B. Dark- and bluish-colored stoma
5. A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 C. Narrowed and flattened stoma
weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. D. Protruding stoma
She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse 2.During the period of induction of labor, a client should be observed carefully for signs of:
should identify that the client is: A. Severe pain
A. G4 T3 P2 A1 L4 B. Uterine tetany
B. G5 T2 P2 A1 L4 C. Hypoglycemia
C. G5 T2 P1 A1 L4 D. Umbilical cord prolapse
D. G4 T3 P1 A1 L4 3.A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is
6. Bleeding and cramping occur with the cervix closed and membranes intact. experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse
A. complete takes.
B. inevitable A. Stop of Pitocin infusion
C. habitual B. Perform a vaginal examination
D. missed C. Reposition the client
E. threatened D. Check the client’s blood pressure and heart rate
7. Some of the products are expelled, but the placenta remains attached. Heavy bleeding and E. Administer oxygen by face mask at 8 to 10 L/min
cramping doesn’t subside until entire placenta is removed. 4.A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The
A. habitual nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following
B. missed would be the initial nursing action?
C. incomplete A. Place the client in Trendelenburg’s position
D. complete B. Call the delivery room to notify the staff that the client will be transported immediately
E. threatened C. Gently push the cord into the vagina
8. Any of the 5 spontaneous abortions occurring with 3 consecutive pregnancies. This condition D. Find the closest telephone and stat page the physician
is a result of weakened cervix that dilates in the 2nd trimester, and expels the fetus. This 5.Which of the following complications during a breech birth the nurse needs to be alarmed?
condition is call INCOMPLETE CERVIX. A. Abruption placenta.
A. habitual B. Caput succedaneum.
B. missed C. Pathological hyperbilirubinemia.
C. incomplete D. Umbilical cord prolapse.
6.The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her A. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal
membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum head
intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental
per minute. The immediate nursing action is to: separation
A. Start oxygen by mask to reduce fetal distress. C. Massaging the fundus to encourage the uterus to contract
B. Examine the woman for signs of a prolapsed cord. D. Applying light traction when delivering the placenta that has already detached from
C. Turn the woman on her left side to increase placental perfusion. the uterine wall
D. Take the woman’s radial pulse while still auscultating the FHR. 4. While assessing a primipara during the immediate postpartum period, the nurse in charge
7.When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus plans to use both hands to assess the client’s fundus to:
for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening A. Prevent uterine inversion
the correct nursing intervention is: B. Promote uterine involution
A. Push back the prolapse cord into the vaginal canal C. Hasten the puerperium period
B. Place the mother on semifowler’s position to improve circulation D. Determine the size of the fundus
C. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman 5.A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage
on trendellenberg position with a group of nurses. Which of the following should be included in the discussion? (Select all
D. Push back the cord into the vagina and place the woman on sims position that apply.)
8.A patient is in labor and has just been told she has a breech presentation. The nurse should be A. Precipitous delivery
particularly alert for which of the following? B. Lacerations
A. Quickening C. Inversion of the uterus
B. Ophthalmia neonatorum D. Oligohydramnios
C. Pica E. Retained placental fragments
D. Prolapsed umbilical cord 1. The main reason for an expected increased need for iron in pregnancy is:
9.Which of the following is the nurse’s initial action when umbilical cord prolapse occurs? A. The mother may have physiologic anemia due to the increased need for red bloodcell
A. Begin monitoring maternal vital signs and FHR mass as well as the fetal requires about 350-400 mg of iron to grow
B. Place the client in a knee-chest position in bed B. The mother may suffer anemia because of poor appetite
C. Notify the physician and prepare the client for delivery C. The fetus has an increased need for RBC which the mother must supply
D. Apply a sterile warm saline dressing to the exposed cord D. The mother may have a problem of digestion because of pica
10. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should: 2. Which of the following is the most likely effect on the fetus if the woman is severely anemic
A. Attempt to replace the cord during pregnancy?
B. Place the client on her left side A. Large for gestational age (LGA) fetus
C. Elevate the client’s hips B. Hemorrhage
D. Cover the cord with a dry, sterile gauze C. Small for gestational age (SGA) baby
1. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery D. Erythroblastosis fetalis
of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse 3. Which of the following would the nurse identify as the initial priority for a child with acute
who’s caring for her should stay alert for: lymphocytic leukemia?
A. Uterine inversion A. Instituting infection control precautions
B. Uterine atony B. Encouraging adequate intake of iron-rich foods
C. Uterine involution C. Assisting with coping with chronic illness
D. Uterine discomfort D. Administering medications via IM injections
2. When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse 4. Which of the following statements best describes hyperemesis gravidarum?
should suspect A. Severe anemia leading to an electrolyte, metabolic, and nutritional imbalances in the
A. Laceration of soft tissues of the cervix and vagina absence of other medical problems.
B. Uterine atony B. Severe nausea and vomiting leading to an electrolyte, metabolic, and nutritional
C. Uterine inversion imbalances in the absence of other medical problems.
D. Uterine hypercontractility C. Loss of appetite and continuous vomiting that commonly results in dehydration and
3. Which of the following techniques during labor and delivery can lead to uterine inversion? ultimately decreasing maternal nutrients
 D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly
internal bleeding
5. Rho(D) immune globulin (RhoGAM) is given to a pregnant woman after delivery and the nurse
is giving information to the patient about the indication of the medication. The nurse determines Answers and Rationales
that the patient understands the purpose of the medication if the patient tells that it will protect her 1. (A) that extended their anal sphincter. Third degree laceration involves all in the
second degree laceration and the external sphincter of the rectum. Options B, C
baby from which of the following?
and D are under the second degree laceration.
A. Developing German Measles. 2. (C) I will have to remain in bed until my due date comes. Placenta previa means
B. Developing Pernicious anemia. that the placenta is the presenting part. On the first and second trimester there is
C. Developing Rh incompatibility. spotting. On the third trimester there is bleeding that is sudden, profuse and
D. Having an RH+ blood. painless.
6. A nurse instructor is about to administer a vitamin K injection to a newborn. The student nurse 3. (D) 18th week of pregnancy. On the 8th week of pregnancy, the uterus is still
asks the instructor regarding the purpose of the injection. The appropriate response would be: within the pelvic area. On the 10th week, the uterus is still within the pelvic area.
On the 12th week, the uterus and placenta have grown, expanding into the
A. “The vitamin K provides active immunity.”
abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis
B. “The vitamin K will prevent the occurrence of hyperbilirubinemia.” and is expanding into the abdominal area.
C. “The vitamin K will protect the newborn from bleeding.” 4. (A) frequency. Pressure and irritation of the bladder by the growing uterus during
D. “The vitamin K will serve as protection against jaundice and anemia.” the first trimester is responsible for causing urinary frequency. Dysuria,
7. The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? incontinence and burning are symptoms associated with urinary tract infection.
A. Anemia 5. (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently
B. Hypoglycemia recommended as an average weight gain in pregnancy. This weight gain consists
of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb;
C. Nitrogen loss
breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.
D. Thrombosis 6. (B) Modify preoperative teaching to meet the needs of either a planned or
8. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse emergency cesarean birth. A key point to consider when preparing the client for a
notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The nurse cesarean delivery is to modify the preoperative teaching to meet the needs of
determines that the client is at risk for which of the following? either planned or emergency cesarean birth, the depth and breadth of instruction
A. A loud mouth will depend on circumstances and time available.
B. Low self-esteem 7. (D) convulsions. Options A, B and C are findings of severe preeclampsia.
Convulsions is a finding of eclampsia—an obstetrical emergency.
C. Hemorrhage
8. (C) Should be restricted because it may stimulate uterine activity.. Coitus is
D. Postpartum infections restricted when there is watery discharge, uterine contraction and vaginal
9. Which of the following conditions is common in pregnant women in the 2nd trimester of bleeding. Also those women with a history of spontaneous miscarriage may be
pregnancy? advised to avoid coitus during the time of pregnancy when a previous miscarriage
A. Mastitis occurred.
B. Metabolic alkalosis 9. (D) assume Sim’s position. When the woman is in Sim’s position, this puts the
weight of the fetus on bed, not on the woman and allows good circulation in the
C. Physiologic anemia
lower extremities.
D. Respiratory acidosis 10. (A) The anterior is large in shape when compared to the posterior fontanel.. The
10. An infant born at 33 weeks’ gestation has anemia of prematurity, which is characterized by an anterior fontanel is larger in size than the posterior fontanel. Additionally, the
inadequate response to erythropoietin. The healthcare provider expects that microscopic anterior fontanel, which is diamond shaped closes at 18 month, whereas the
examination of this infant’s red blood cells would reveal. posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither
A. Normal hemoglobin in each cell. fontanel should appear bulging, which may indicate increases ICP or sunken,
B. Large, pale cells. which may indicate hydration.
11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months and is tripled
C. Small and immature cells.
at 12 months.
D. Cells of normal size. 12. (B) To promote uterine contraction. Oxytocin is a hormone produced by the
E. Small, irregularly shaped cells. pituitary gland that produces intermittent uterine contractions, helping to promote
uterine involution.
13. (B) 100 beats per minute. The normal heart rate for a newborn that is sleeping is
approximately 100 beats per minute. If the newborn was awake, the normal heart
rate would range from 120 to 160 beats per minute.
 14. (D) Trust vs. Mistrust. The child with Down syndrome will go through the same development that progresses from center of the body to the extremities. Example: a
first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should child first develops arm movement before fine-finger movement. Different parts of the
concentrate on developing on bond between the primary caregiver and the child. body grows at different range because some body tissue mature faster than the other
15. (A) Irreversible brain damage. The child with PKU must maintain a strict low such as the neurologic tissues peaks its growth during the first years of life while the
phenylalanine diet to prevent central nervous system damage, seizures and genital tissue doesn’t till puberty. Also G&D is predictable in the sequence which a child
eventual death. normally precedes such as motor skills and behavior. Lastly G&D can never be
16. (B) Preschool. During preschool, this is the time when children do imitative play, modified .
imaginative play—the occurrence of imaginative playmates, dramatic play where 3. A. Make believe. Make believe is most appropriate because it enhances the imitative
children like to act, dance and sing. play and imagination of the preschooler. C and D are for infants while letter A is B is
17. (D) Saying “mama” or “dada” for the first time at 18 months of age.. A child should recommended for schoolers because it enhances competitive play.
say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all 4. C. Has the ability to try new things. Erickson defines the developmental task of a
normal assessments of language development of a child. preschool period is learning Initiative vs. Guilt. Children can initiate motor activities of
18. (C) Ignore her behavior as long as she does not hurt herself and others.. If a child various sorts on their own and no longer responds to or imitate the actions of other
is trying to get attention or trying to get something through tantrums—ignore children or of their parents.
his/her behavior. 5. C. naïve instrumental orientation. According to Kohlber, a preschooler is under Pre-
19. (B) 4 inches. From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. conventional where a child learns about instrumental purpose and exchange, that is
From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month. they will something do for another if that that person does something with the child in
20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory distress and return. Letter A is applicable for Toddlers and letter B is for a School age child.
bronchospasm despite of treatment and interventions. Mechanical ventilation 6. A. Long. The average length of full-term babies at birth is 20 in. (51 cm), although the
maybe needed due to respiratory failure. normal range is 46 cm (18 in.) to 56 cm (22 in.).
21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s tumor is caused 7. A. From cognitive to psychosexual. Growth and development occurs in cephalo-caudal
by chromosomal abnormalities, most common kidney cancer among children (head to toe), proximo-distal (trunk to tips of the extremities and general to specific, but
characterized by abdominal mass, hematuria, hypertension and fever. it doesn’t occurs in cognitive to psychosexual because they can develop at the same
22. (A) blurred vision. Danger signs that require prompt reporting are leaking of time.
amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated 8. C. Trust vs. mistrust. According to Erikson, children 0-18 months are under the
blood pressure. Nasal stuffiness, breast tenderness, and constipation are developmental task of Trust vs. Mistrust.
common discomforts associated with pregnancy. 9. A. Disappears in about a year. Mongolian spots are stale grey or bluish patches of
23. (B) irritability, purulent drainage in middle ear, nasal congestion and discoloration commonly seen across the sacrum or buttocks due to accumulation of
cough. Irritability, purulent drainage in middle ear, nasal congestion and cough, melanocytes and they disappears in 1 year. They are not linked to steroid use and
fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis pathologic conditions.
media. Acute otitis media is common in children 6 months to 3 years old and 8 10. D. Increased RR. Hypothermia is inaccurate cause normally, temperature of a newborn
years old and above. Breast fed infants have higher resistance due to protection drop, Also a child under cold stress will kick and cry to increase the metabolic rate
of Eustachian tubes and middle ear from breast milk. thereby increasing heat so B isn’t a good choice. A newborn doesn’t have the ability to
24. (D) Kangaroo care. Kangaroo care is the use of skin-to-skin contact to maintain shiver, so letter B and C is wrong. A newborn will increase its RR because the NB will
body heat. This method of care not only supplies heat but also encourages need more oxygen because of too much activity.
parent-child interaction. 11. A. Mother’s breast. Place it at the mother’s breast for latch-on. (Note: for NSD breast
25. (B) Use of a high-SPF sunblock. Without melanin production, the child with feed ASAP while for CS delivery, breast feed after 4 hours)
albinism is at risk for severe sunburns. Maximum sun protection should be taken, 12. A. Direct Coomb’s. Coomb’s test is the test to determine if RH antibodies are present.
including use of hats, long sleeves, minimal time in the sun and high-SPF Indirect Coomb’s is done to the mother and Direct Coomb’s is the one don’t to the baby.
sunblock, to prevent any problems. Blood culture and Platelet count doesn’t help detect RH antibodies.
13. A. Place the crib beside the wall. Placing the crib beside the wall is inappropriate
Answers and Rationales because it can provide heat loss by radiation. Doing Kangaroo care or hugging the
1. B. a decline in growth rate. During the Preschooler stage growth is very minimal. baby, mechanical pressure or incubators and drying and wrapping the baby will help
Weight gain is only 4.5lbs (2kgs) per year and Height is 3.5in (6-8cm) per year. conserve heat.
 Review: 14. B. Increase ICP. Hypoglycemia may occur due to increase metabolic rate, and because
of newborns are born slightly acidic, and they catabolize brownfat which will produce
 Most rapid growth and development- Infancy ketones which is an acid will cause metabolic acidosis. Also a NB with severe
 Slow growth- Toddler hood and Preschooler hypothermia is in high risk for kernicterus (too much bilirubin in the brain) can lead to
 Slower growth- School age Cerebral palsy. There is no connection in the increase of ICP with hypothermia. (NOTE:
 Rapid growth- Adolescence pathognomonic sign of Kernicterus in adult- asterexis, or involuntary flapping of the
2. D. Rate and pattern of growth can be modified. Growth and development occurs in hand.)
cephalo-caudal meaning development occurs through out the body’s axis. Example: the
child must be able to lift the head before he is able to lift his chest. Proximo-distal is
15. D. Foramen Ovale. Foramen ovale is opening between two atria, Ductus venosus is the esteem not high level. Also child abuse can happen in all socio-economic status not just
shunt from liver to the inferior vena cava, and your Ductus Arteriosus is the shunt from on low socio-economic status.
the pulmonary artery to the aorta. 29. C. Unexplained symptoms of diarrhea, vomiting and apnea with no organic
16. B. Shifting of pressures from right side to the left side of the heart. During feto-placental basis. Munchausen syndrome by Proxy is the fabrication or inducement of an illness by
circulation, the pressure in the heart is much higher in the right side, but once one person to another person, usually mother to child. It is characterized by symptoms
breathing/crying is established, the pressure will shift from the R to the L side, and will such as apnea and siezures, which may be due to suffocation, drugs or poisoning,
facilitate the closure of Foramen Ovale. (Note: that is why you should position the NB in vomiting which can be induced with poisons and diarrhea with the use of laxatives.
R side lying position to increase pressure in the L side of the heart.) Letter A can be seen in a Physical abuse, Letter B for sexual abuse and Letter C is for
 Review: Physical Neglect.
 Increase PO2-> closure of ductus arteriosus 30. B. Offering large amount of fresh fruits and vegetables. A child with HIV is
 Decreased bloodflow -> closure of the ductus venosus immunocompromised. Fresh fruits and vegetables, which may be contaminated with
organisms and pesticides can be harmful, if not fatal to the child, therefore these items
 Circulation in the lungs is initiated by -> lung expansion and should be avoided.
pulmonary ventilation
31. C. Decrease hypoxic spells. The correct answer is letter C. Though letter B would be a
 What will sustain 1st breath-> decreased artery pressure good answer too, this goal is too vague and not specific. Nursing interventions will not
 What will complete circulation-> cutting of the cord solely promote normal G&D unless he will undergo surgical repair. So decreasing
17. B. Atrial Septal defect. Foramen ovale is the opening between two Atria so, if its will not Hypoxic Spells is more SMART. Letter A and D are inappropriate.
close Atrial Septal defect can occur. 32. B. Place her in knee chest position. The immediate intervention would be to place her
18. A. Sitting up. The correct position is making the child having an upright sitting position on knee-chest or “squatting” position because it traps blood into the lower extremities.
with the head slightly tilted forward. This position will minimize the amount of blood Though also letter C would be a good choice but the question is asking for “Immediate”
pressure in nasal vessels and keep blood moving forward not back into the so letter B is more appropriate. Letter A and D are incorrect because its normal for a
nasopharynx, which will have the choking sensation and increase risk of aspiration. child who have ToF to have hypoxic or “tets” spells so there is no need to transfer her to
Choices b, c, d, are inappropriate cause they can cause blood to enter the the NICU or to alert the Pediatrician.
nasopharynx. 33. D. Blalock-Taussig. Blalock-Taussig procedure its just a temporary or palliative surgery
19. B. Eustachian tube. This is because children has short, horizontal Eustachian tubes. which creates a shunt between the aorta and pulmonary artery so that the blood can
The dysfunction in the Eustachian tube enables bacterial invasion of the middle ear and leave the aorta and enter the pulmonary artery and thus oxygenating the lungs and
obstructs drainage of secretions. return to the left side of the heart, then to the aorta then to the body. This procedure
20. C. Brain damage. One of the complication of recurring acute otitis media is risk for also makes use of the subclavian vein so pulse is not palpable at the right arm. The full
having Meningitis, thereby causing possible brain damage. That is why patient must repair for ToF is called the Brock procedure. Raskkind is a palliative surgery for TOGA.
follow a complete treatment regimen and follow up care. A,B and D are not 34. A. Friendly with the nurse. Because toddlers views hospitalization is abandonment,
complications of AOM. separation anxiety is common. Its has 3 phases: PDD (parang c puff daddy LOL) 1.
21. A. Riding a tricycle. Answer is A, riding a tricycle is appropriate for a 3 y/o child. Protest 2. despair 3. detachment (or denial). Choices B, C, D are usually seen in a child
Hopping on one foot can be done by a 4 y/o child, as well as catching and throwing a with separation anxiety (usually in the protest stage).
ball over hand. Skipping can be done by a 5 y/o.  REVIEW:
22. A. Doubling of birth weight. During the first 6 months of life the weight from birth will be
 Separation anxiety begin at: 9 months
doubled and as soon as the baby reaches 1 year, its birth weight is tripled.
23. C. Doctor and nurse kits. Letter C is appropriate because it will enhance the creativity  Peaks: 18 months
and imagination of a pre-school child. Letter B and D are inappropriate because they 35. D. Anticipatory grieving r/t gravity of child’s physical status. In this item letter A and be
are too complex for a 4 y/o. Push-pull toys are recommended for infants. are inappropriate response so remove them. The possible answers are C and D. Fear
24. B. “He’s just a bit dead”. A 5 y/o views death in “degrees”, so the child most likely will defined as the perceived threat (real or imagined) that is consciously recognized as
say that “he is just a bit dead”. Personification of death like boogeyman occurs in ages 7 danger (NANDA) is applicable in the situation but its defining characteristics are not
to 9 as well as denying death can if they will be good. Denying death using jokes and applicable. Crying per se can not be a subjective cue to signify fear, and most of the
attributing life qualities to death occurs during age 3-5. symptoms of fear in NANDA are physiological. Anticipatory grieving on the other hand
25. D. Infant have greater body surface area than adults. Infants have greater body surface are intellectual and EMOTIONAL responses based on a potential loss. And remember
area than adult, increasing their risk to F&E imbalances. Also infants cant concentrate a that procedures like this cannot assure total recovery. So letter D is a more appropriate
urine at an adult level and their metabolic rate, also called water turnover, is 2 to 3 times Nursing diagnosis.
higher than adult. Plus more fluids of the infants are at the ECF spaces not in the ICF 36. B. Epiglottitis. Acute and sever inflammation of the epiglottis can cause life threatening
spaces. airway obstruction, that is why its always treated as a medical emergency. NSG
26. C. Metabolic acidosis. Remember that Aspirin is acid (Acetylsalicylic ACID). intervention : Prepare tracheostomy set at bed side. LTB, can also cause airway
27. D. Blisters and edema. The question was asking for a SYSTEMIC clinical manifestation, obstruction but its not an emergency. Asthma is also not an emergency. CF is a chronic
Letters A,B and C are systemic manifestations while Blisters and Edema weren’t. disease, so its not a medical emergency.
28. D. Problematic pregnancies. Typical factors that may be risk for Child abuse are 37. C. “We’ll make sure he avoids exercise to prevent asthma attacks”. Asthmatic children
problematic pregnancies, chronic exposure to stress not periodic, low level of self don’t have to avoid exercise. They can participate on physical activities as tolerated.
Using a bronchodilator before administering steroids is correct because steroids are just
 anti-inflammatory and they don’t have effects on the dilation of the bronchioles. OF 52. C. Ortolani’s sign. Correct answer is Ortolani’s sign; it is the abnormal clicking sound
course letters A and B are obviously correct. when the hips are abducted. The sound is produced when the femoral head enters the
38. C. Height and weight. Dental problems are more likely to occur in children under going acetabulum. Letter A is wrong because its should be “asymmetrical gluteal fold”. Letter
TCA therapy. Mouth dryness is a expected side effects of Ritalin since it activates the B and C are not applicable for newborns because they are seen in older children.
SNS. Also loss of appetite is more likely to happen, not increase in appetite. The correct 53. D. Hypospadias. Hypospadias is a c condition in which the urethral opening is located
answer is letter C, because Ritalin can affect the child’s G&D. Intervention: medication below the glans penis or anywhere along the ventral surface of the penile shaft.
“holidays or vacation”. (This means during weekends or holidays or school vacations, Epispadias, the urethral meatus is located at the dorsal surface of the penile shaft.
where the child wont be in school, the drug can be withheld.) (Para di ka malilto, I-alphabetesize mo Dorsal, (Above) eh mauuna sa Ventral (Below) ,
39. C. Expanded program on immunization Epis mauuna sa Hypo.)
40. B. Epidemiologic situation. Letters A, C and D are not included in the principles of EPI. 54. C. 40 lb and 40 in. Basta tandaan ang rule of 4! 4 years old, 40 lbs and 40 in.
41. D. Target setting 55. A. Sucking ability. Because of the defect, the child will be unable to form the mouth
42. A. Interruption of transmission adequately arounf the nipple thereby requiring special devices to allow feeding and
43. B. MMR. MMR or Measles, Mumps, Rubella is a vaccine furnished in one vial and is sucking gratification. Respiratory status may be compromised when the child is fed
routinely given in one injection (Sub-Q). It can be given at 15 months but can also be improperly or during post op period.
given as early as 12th month. 56. D. Body image. Because of edema, associated with nephroitic syndrome, potential self
44. B. Severe pneumonia. For a child aging 2months up to 5 years old can be classified to concept and body image disturbance related to changes in appearance and social
have sever pneumonia when he have any of the following danger signs: isolation should be considered.
 Not able to drink 57. A. G6PD. G6PD is the premature destruction of RBC when the blood is exposed to
 Convulsions antioxidants, ASA (ano un? Aspirin), legumes and flava beans.
 Abnormally sleepy or difficult to wake 58. B. Phenestix test. Phenestix test is a diagnostic test which uses a fresh urine sample
(diapers) and mixed with ferric chloride. If positive, there will be a presence of green
 Stridor in calm child or spots at the diapers. Guthrie test is another test for PKU and is the one that mostly
 Severe under-nutrition used. The specimen used is the blood and it tests if CHON is converted to amino acid.
45. D. 50 pbm. A child can be classified to have Pneumonia (not severe) if: 59. B. Methionine. Hemocystenuria is the elevated excretion of the amino acid
 the young infant is less than 2 months- 60 bpm or more hemocystiene, and there is inability to convert the amino acid methionine or cystiene.
 if the child is 2 months up to less than 12 months- 50 bpm or more So dietary restriction of this amino acids is advised. This disease can lead to mental
 if the child is 12 months to 4 y/o- 40 bpm or more retardation.
46. B. PD no. 6 Presidential Proclamation no. 6 (April 3, 1986) is the “Implementing a 60. C. Neutramigen. Neutramien is suggested for a child with Galactosemia. Lofenalac is
United Nations goal on Universal Child Immunization by 1990”. PD 996 (September 16, suggested for a child with PKU.
1976) is “providing for compulsory basic immunization for infants and children below 8
years of age. PD no. 46 (September 16, 1992) is the “Reaffirming the commitment of Answers and Rationales
the Philippines to the universal Child and Mother goal of the World Health Assembly. 1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions;
RA 9173 is of course the “Nursing act of 2002” prolonged contractions will jeopardize the safetyof the fetus and necessitate
47. B. 100,000 “IU”. An infant aging 6-11 months will be given Vitamin supplementation of discontinuing the drug.
100, 000 IU and for Preschoolers ages 12-83 months 200,000 “IU” will be given. 2. B. It is of paramount importance to prevent the client from hurting himself or herself or
48. C. “Did the child have chest indrawing?”. The CARI program of the DOH includes the others.
“ASK” and “LOOK, LISTEN” as part of the assessment of the child who has suspected 3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or
Pneumonia. Choices A, B and D are included in the “ASK” assessment while Chest cold liquids should be avoided because they may irritate the throat. Red liquids should
indrawings is included in the “LOOK, LISTEN” and should not be asked to the mother. be avoided because they give the appearance of blood if the child vomits. Milk and milk
49. A. Aganglionic Mega colon. Failure to pass meconium of Newborn during the first 24 products including pudding are avoided because they coat the throat, cause the child to
hours of life may indicate Hirschsprung disease or Congenital Aganglionic Megacolon, clear the throat, and increase the risk of bleeding.
an anomaly resulting in mechanical obstruction due to inadequate motility in an 4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of
intestinal segment. B, C, and D are not associated in the failure to pass meconium of mucous membranes.
the newborn. 5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC
50. B. Apple slices. Grapes is in appropriate because of its “balat” that can cause choking. performance criteria for a tuberculosis respirator.
A glass of milk is not a good snack because it’s the most common cause of Iron- 6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-
deficiency anemia in children (milk contains few iron), A glass of cola is also not angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes
appropriate cause it contains complex sugar. (walang kinalaman ang asthma dahil ala normal accommodation, making night driving difficult and hazardous, reducing the
naman itong diatery restricted foods na nasa choices.) client’s ability to read for extended periods and making participation in games with fast-
51. D. IPV. IPV or Inactivated polio vaccine does not contain live micro organisms which moving objects impossible.
can be harmful to an immunocompromised child. Unlike OPV, IPV is administered via 7. B. This stops the sucking of air through the tube and prevents the entry of
IM route. contaminants. In addition, clamping near the chest wall provides for some stability and
may prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be 26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is
compressed by the after-coming head in a breech birth. specific for HCG, and accuracy is not compromised by confusion with LH.
9. B. It is important to externalize the anger away from self. 27. D. Surgery and anesthesia can increase mucus production. Deep breathing and
10. D. Development normally proceeds cephalocaudally; so the first major developmental coughing are essential to prevent atelectasis and pneumonia in the client’s only
milestone that the infant achieves is the ability to hold the head up within the first 8-12 remaining lung.
weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant 28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and
would not be able to achieve this milestone. conjunctivitis from Chlamydia.
11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally 29. D. The client may perceive this as avoidance, but it is more important to redirect back to
speaking, a nurse should not accept telephone orders. However, if it is necessary to the client, especially in light of the manipulative behavior of drug abusers and
take one, follow the hospital’s policy regarding telephone orders. Failure to adolescents.
followhospital policy could be considered negligence. In this case, the nurse was new 30. C. It describes a democratic process in which all members have input in the client’s
and did not know the hospital’s policy concerning telephone orders. The nurse was also care.
unfamiliar with the doctor and the client. Therefore the nurse should not take the order 31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of
unless a) no one else is available and b) it is an emergency situation. oxytocin released by the posterior pituitary gland.
12. C. The nurse is obligated to inform the nurse manager about changes in the condition of 32. B. In case management, the nurse assumes total responsibility for meeting the needs of
the client, which may change the decision made by the nurse manager. the client during the entire time on duty.
13. A. Perinatal risk factors for the development of Down syndrome include advanced 33. A. Smoke inhalation affects gas exchange.
maternal age, especially with the first pregnancy. 34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation
14. B. Assignments should be based on scope of practice and expertise. occurs during this period, conception may result.
15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for 35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of
digoxin toxicity due to the loss of potassium. The child and parents should be taught waking in the early morning).
what foods are high in potassium, and the child should be encouraged to eat a high- 36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the
potassium diet. In addition, the child’s serum potassium level should be carefully maternal and fetal heart rates and rule out fetal Bradycardia.
monitored. 37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
16. A. The responsible for an accurate informed consent is the physician. An exception to 38. A. This suggests that the level of consciousness is decreasing.
this answer would be a life-threatening emergency, but there are no data to support 39. D. An advance directive is a form of informed consent, and only a competent adult or
another response. the holder of a durable power of attorney has the right to consent or refuse treatment. If
17. D. Asking the client to cough and take a deep breath will help determine if the chest the spouse does not hold the power of attorney, the decisions of the holder, even if
tube is kinked or if the lungs has reexpanded. opposed by the spouse, are enforced.
18. B. Every event that exposes a client to harm should be recorded in an incident report, 40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a
as well as reported to the appropriate supervisors in order to resolve the current client with schizophrenic symptoms is being disruptive.
problems and permit the institution to prevent the problem from happening again. 41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart withdrawn.
rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and 42. D. The priority for this client is being able to establish an airway.
would necessitate holding the medication and notifying the physician. 43. A. Signs of placental separation include a change in the shape of the uterus from ovoid
20. B. This option is least threatening. to globular.
21. D. In preparing the client for discharge that is receiving prednisone, the nurse should 44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that
caution the client to (a) take oral preparations after meals; (b) remember that routine lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and
checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR signs of any gastrointestinal or internal bleeding.
CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store 45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep
the medication in a light-resistant container. breathing is painful. Additionally, there is a greater incisional pull each time the person
22. A. Progesterone also reduces smooth muscle motility in the urinary tract and moves than there is with abdominal surgery. Incisional pain following nephrectomy
predisposes the pregnant woman to urinary tract infections. Women should contact their generally requires analgesics administration every 3-4 hours for 24-48 hours after
doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal surgery. Therefore, turning, coughing and deep-breathing exercises should be planned
muscles; limiting fluids at bedtime reduces the possibility of being awakened by the to maximize the analgesic effects.
necessity of voiding. 46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical
23. B. This is the proper use of anger. mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
24. C. There are several models of case management, but the commonality is 47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s
comprehensive coordination of care to better predict needs of high-risk clients, position to promote drainage and to prevent possible complications.
decrease exacerbations and continually monitor progress overtime. 48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.
25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration 49. A. The recommended procedure for administering eyedrops to any client calls for the
know as purple glove syndrome; infusing into a smaller vein is not appropriate. drops to be placed in the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is 71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion,
difficult to recognized and evaluate because it is not apparent. ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate
51. C. Erythema toxicum is the normal, nonpathological macular newborn rash. premature rupture of the membrane.
52. D. The family needs to understand what brain death is before talking about organ 72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas
donation. They need time to accept the death of their family member. An environment exchange.
conducive to discussing an emotional issue is needed. 73. A. Somatoform disorders provide a way of coping with conflicts.
53. A. Bending from the waist in pregnancy tends to make backache worse. 74. C. Immunization should never be mixed together in a syringe, thus necessitating three
54. B. Support and limit setting decrease anxiety and provide external control. separate injections in three sites. Note: some manufacturers make a premixed
55. C. The stoma drainage bag is applied in the operating room. Drainage from the combination of immunization that is safe and effective.
ileostomy contains secretions that are rich in digestive enzymes and highly irritating to 75. A. Clients with radioactive implants should be positioned flat in bed to prevent
the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin dislodgement of the vaginal packing. The client may roll to the side for meals but the
exposed to these enzymes even for a short time becomes reddened, painful and upper body should not be raised more than 20 degrees.
excoriated. 76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in
56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If
ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization the ingested substance “burned” the esophagus going down, it will “burn” the
could occur from sperm deposited before ovulation. esophagus coming back up when the child begins to vomit after administration of syrup
57. C. An advocate role encourage freedom of choice, includes speaking out for the client, of ipecac.
and supports the client’s best interests. 77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage.
58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce 78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is
the possibility of transmitting infection to one’s sexual partner. the first priority.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense 79. C. The nurse who is supervising others has a legal obligation to determine that they are
of hand washing decreases anxiety by avoiding group therapy. competent to perform the assignment, as well as legal obligation to provide adequate
60. D. Denial is a very strong defense mechanism used to allay the emotional effects of supervision.
discovering a potential threat. Although denial has been found to be an effective 80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the
mechanism for survival in some instances, such as during natural disasters, it may in calculi.
greater pathology in a woman with potential breast carcinoma. 81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has
61. B. The registered nurse cannot delegate the responsibility for assessment and failed to produce a pregnancy. Older couples will experience a longer time to get
evaluation of clients. The status of the client in restraint requires further assessment to pregnant.
determine if there are additional causes for the behavior. 82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine
62. C. The client with chest pain may be having a myocardial infarction, and immediate clearance test.
assessment and intervention is a priority. 83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad
63. B. Is correct because semen analysis requires that a freshly masturbated specimen be opening for the client to elaborate feelings.
obtained after a rest (abstinence) period of 48-72 hours. 84. C. The behavior should be stopped. The first is to remind the staff that confidentiality
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant. maybe violated.
65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned 85. C. With a right-sided cerebrovascular accident the client would have left-sided
before deflation, the secretions may be aspirated. hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate
66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the the transfer.
air. Clients need to be taught to cover their nose and mouth with tissues when sneezing 86. D. Legos are small plastic building blocks that could easily slip under the child’s cast
or coughing. Chemotherapy generally renders the client noninfectious within days to a and lead to a break in skin integrity and even infection. Pencils, backscratchers, and
few weeks, usually before cultures for tubercle bacilli are negative. Until chemical marbles are some other narrow or small items that could easily slip under the child’s
isolation is established, many institutions require the client to wear a mask when visitors cast and lead to a break in skin integrity and infection.
are in the room or when the nurse is in attendance. Client should be in a well-ventilated 87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
room, without air recirculation, to prevent air contamination. 88. B. The submission of reports about incidents that expose clients to harm does not
67. A. It is best to establish baseline information first. remove the obligation to report ongoing behavior as long as the risk to the client
68. B. Listening is probably the most effective response of the four choices. continues.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs
hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of
loose). 1000mg of tetracycline. In this case, the child is being given this medication four times a
70. C. A high fever accompanied by a body rash could indicate that the child has a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of
communicable disease and would have exposed other students to the infection. The tetracycline divided by four doses.)
school nurse would want to investigate this telephone call immediately so that plans 90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine
could be instituted to control the spread of such infection. contractions and lengthen the duration of subsequent labors.
 91. A. Personality disorders stem from a weak superego, implying a lack of adequate 7. Answer: D. Incessant crying. A newborn infant born to a woman using drugs is
controls. irritable. The infant is overloaded easily by sensory stimulation. The infant may
92. C. The basal body temperature is the lowest body temperature of a healthy person that cry incessantly and posture rather than cuddle when being held.
is taken immediately after waking and before getting out of bed. The BBT usually varies 8. Answer: C. “Newborn infants are deficient in vitamin K, and this injection prevents
from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time your infant from abnormal bleeding.” Vitamin K is necessary for the body to
of ovulation, a slight drop in temperature may be seen, after ovulation in concert with synthesize coagulation factors. Vitamin K is administered to the newborn infant to
the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. prevent abnormal bleeding. Newborn infants are vitamin K deficient because the
This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred. bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin
93. A. This choice implies concern for client care and self-improvement. K. The infant’s bowel does not have support the production of vitamin K until
94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the bacteria adequately colonizes it by food ingestion.
various organs, tissues, and structures. 9. Answer: A. Connect the resuscitation bag to the oxygen outlet. The highest
95. C. This response does not contradict the client’s perception, is honest, and shows priority on admission to the nursery for a newborn with low Apgar scores is
empathy. airway, which would involve preparing respiratory resuscitation equipment. The
96. D. Tension on round ligament occurs because of the erect human posture and pressure other options are also important, although they are of lower priority.
exerted by the growing fetus. 10. Answer: C. Vastus lateralis.
97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an 11. Answer: B. “I will flush the eyes after instilling the ointment.” Eye prophylaxis
emergency outside of the scope of employment, therefore nurses who do not stop are protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis.
not liable for suit. The eyes are not flushed after instillation of the medication because the flush will
98. C. Although reducing environment stimuli and activity is necessary for a woman with wash away the administered medication.
mild preeclampsia, she will most probably have bathroom privileges. 12. Answer: A. Establish an airway for the baby. The nurse should position the baby
99. B. A normal respiratory rate for a newborn is 30-40 breaths per minute. with head lower than chest and rub the infant’s back to stimulate crying to
100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol promote oxygenation. There is no haste in cutting the cord.
withdrawal (often unsuspected on a surgical unit.) 13. Answer: A. Heart rate. The heart rate is vital for life and is the most critical
Answers and Rationales observation in Apgar scoring. Respiratory effect rather than rate is included in the
Apgar score; the rate is very erratic.
1. Answer: D. Drying the infant in a warm blanket. Evaporation of moisture from a 14. Answer: D. Respirations, pulse, temperature. This sequence is least disturbing.
wet body dissipates heat along with the moisture. Keeping the newborn dry by Touching with the stethoscope and inserting the thermometer increase anxiety
drying the wet newborn infant will prevent hypothermia via evaporation. and elevate vital signs.
2. Answer: A. Document the findings. The penis is normally red during the healing 15. Answer: C. 120 and 160. The heart rate varies with activity; crying will increase
process. A yellow exudate may be noted in 24 hours, and this is a part of normal the rate, whereas deep sleep will lower it; a rate between 120 and 160 is
healing. The nurse would expect that the area would be red with a small amount expected.
of bloody drainage. If the bleeding is excessive, the nurse would apply gentle 16. Answer: B. 60. The respiratory rate is associated with activity and can be as rapid
pressure with sterile gauze. If bleeding is not controlled, then the blood vessel as 60 breaths per minute; over 60 breaths per minute are considered tachypneic
may need to be ligated, and the nurse would contact the physician. Because the in the infant.
findings identified in the question are normal, the nurse would document the 17. Answer: B. Irregular, abdominal, 30-60 per minute, shallow. Normally the
assessment. newborn’s breathing is abdominal and irregular in depth and rhythm; the rate
3. Answer: B. Tachypnea and retractions. The infant with respiratory distress ranges from 30-60 breaths per minute.
syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, 18. Answer: A. Monitoring for the passage of meconium each shift. Bilirubin is
chest wall retractions, or audible grunts. excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
4. Answer: C. Place the tape measure under the infants head, wrap around the 19. Answer: A. Milia. Milia occur commonly, are not indicative of any illness, and
occiput, and measure just above the eyes. To measure the head circumference, eventually disappear.
the nurse should place the tape measure under the infant’s head, wrap the tape 20. Answer: A. Screening for PKU. By now the newborn will have ingested an ample
around the occiput, and measure just above the eyebrows so that the largest area amount of the amino acid phenylalanine, which, if not metabolized because of a
of the occiput is included. lack of the liver enzyme, can deposit injurious metabolites into the bloodstream
5. Answer: D. Continue to breastfeed every 2-4 hours. Breast feeding should be and brain; early detection can determine if the liver enzyme is absent.
initiated within 2 hours after birth and every 2-4 hours thereafter. The other 21. Answer: B. Showing by example and explanation how to care for the
options are not necessary. infant. Teaching the mother by example is a non-threatening approach that allows
6. Answer: C. Instillation of the preparation into the lungs through an endotracheal her to proceed at her own pace.
tube. The aim of therapy in RDS is to support the disease until the disease runs 22. Answer: D. Helps the lungs remain expanded after the initiation of
its course with the subsequent development of surfactant. The infant may benefit breathing. Surfactant works by reducing surface tension in the lung. Surfactant
from surfactant replacement therapy. In surfactant replacement, an exogenous allows the lung to remain slightly expanded, decreasing the amount of work
surfactant preparation is instilled into the lungs through an endotracheal tube. required for inspiration.
23. Answer: B. Do nothing because acrocyanosis is normal in the 40. Answer: C. Poor wake and sleep patterns. Altered sleep patterns are caused by
neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a
neonate (also called peripheral cyanosis), is a normal finding and shouldn’t last characteristic generally noted. Low birth weight is a physical defect seen in
more than 24 hours after birth. neonates with FAS. Neonates with FAS generally have a low threshold for
24. Answer: B. Hypoglycemia. Neonates of mothers with diabetes are at risk for stimulation.
hypoglycemia due to increased insulin levels. During gestation, an increased
amount of glucose is transferred to the fetus across the placenta. The neonate’s
liver cannot initially adjust to the changing glucose levels after birth. This may
result in an overabundance of insulin in the neonate, resulting in hypoglycemia.
25. Answer: D. Jaundice within the first 24 hours of life. The neonate with ABO blood
incompatibility with its mother will have jaundice (pathologic) within the first 24
hours of life. The neonate would have a positive Coombs test result.
26. Answer: C. Desquamation of the epidermis. Postdate fetuses lose the vernix
caseosa, and the epidermis may become desquamated. These neonates are
usually very alert. Lanugo is missing in the postdate neonate.
27. Answer: C. Respiratory depression. Magnesium sulfate crosses the placenta and
adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
28. Answer: D. Macrosomia. Neonates of mothers with diabetes are at increased risk
for macrosomia (excessive fetal growth) as a result of the combination of the
increased supply of maternal glucose and an increase in fetal insulin.
29. Answer: B. Convection. Convection heat loss is the flow of heat from the body
surface to the cooler air.
30. Answer: D. It involves swelling of tissue over the presenting part of the presenting
head. Caput succedaneum is the swelling of tissue over the presenting part of the
fetal scalp due to sustained pressure; it resolves in 3-4 days.
31. Answer: D. Group B beta-hemolytic streptococci. Transmission of Group B beta-
hemolytic streptococci to the fetus results in respiratory distress that can rapidly
lead to septic shock.
32. Answer: C. Quiet alert state. When caring for a neonate experiencing drug
withdrawal, the nurse needs to be alert for distress signals from the neonate.
Stimuli should be introduced one at a time when the neonate is in a quiet and
alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are
distress signals that the neonate cannot handle stimuli at that time.
33. Answer: C. Keep the cord dry and open to air. Keeping the cord dry and open to
air helps reduce infection and hastens drying.
34. Answer: D. Vernix.
35. Answer: C. Lecithin to sphingomyelin ratio more than 2:1. Lecithin and
sphingomyelin are phospholipids that help compose surfactant in the lungs;
lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
36. Answer: D. Cover the neonates head with a cap. Covering the neonates head
with a cap helps prevent cold stress due to excessive evaporative heat loss from
the neonate’s wet head. Vitamin K can be given up to 4 hours after birth.
37. Answer: A. Bradycardia. Hypothermic neonates become bradycardic proportional
to the degree of core temperature. Hypoglycemia is seen in hypothermic
neonates.
38. Answer: D. Leathery, cracked, and wrinkled skin. Neonatal skin thickens with
maturity and is often peeling by post term.
39. Answer: D. Obtain an order for IV fluid administration. Assessment findings
indicate that the neonate is in respiratory distress—most likely from transient
tachypnea, which is common after cesarean delivery. A neonate with a rate of 80
breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory
rate returns to normal. To allow for close observation for worsening respiratory
distress, the neonate should be kept unclothed in the radiant warmer.